News From ACFAS

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Last week you should have received an e-mail from ACFAS President Glenn M. Weinraub, DPM, FACFAS, inviting you to take an important survey on your educational needs. If you haven’t already, please take a few minutes to share your opinions. ACFAS will be sending follow-up e-mails in case you missed the original message.

When you receive your e-mail, just click on the link to take this completely confidential survey. An independent CME research firm will report only aggregate results, not individual responses.

If you complete the survey by this Friday, April 29, you’ll be entered in a drawing to win one of three $100 American Express gift cards. ACFAS looks to YOU to learn how to improve our educational programming. Thank you for your participation!
The ACFAS Board of Directors has approved a new position statement that calls for uniform licensure of DPMs and not bifurcated licenses along the lines of board certification. The statement also makes the point that licensure signals the safe entry and minimal competence of a practitioner entering into practice, and is not permission to practice beyond competency. A DPM’s level of competency and scope of practice are properly determined by the credentialing and privileging processes of healthcare institutions and the rulemaking authority of boards of podiatric medicine or other sanctioned regulatory bodies.

The entire statement is available at acfas.org/positions.
Register today for ACFAS’ Practice Management/Coding Workshop, May 14–15, in Cleveland, and get a unique, value-added benefit: a private consultation with ACFAS coding and billing expert Douglas G. Stoker, DPM, FACFAS. For more information on scheduling a coding consultation at the course, e-mail kristin.hellquist@acfas.org. And visit the ACFAS website for registration and the complete brochure.
While you’re considering adoption of an electronic health record (EHR) system, remember that your practice can benefit from participating in the Medicare EHR Incentive Program. This program now offers attestation through the Centers for Medicare and Medicaid Services (CMS) online system. CMS has also posted multiple resources for eligible providers and hospitals who want to meet the “meaningful use” requirements for EHRs.

CMS reports that about 50 percent of the 210,000 Medicare Part B professionals who participated in the Physician Quality Reporting System (PQRS) in 2009 received bonus payments for providing data on various quality measures. More information on the CMS programs is available here.

ACFAS BenefitsPartner EHR Prep-Select, developed by Welch Allyn, can help you and all your practice partners, regardless of specialty, choose the right EHR system for your practice. Visit Welch Allyn’s ACFAS member website to learn more.
You may not have time to read all the research you’d like to, but in just a few minutes you can catch up with ACFAS’ Scientific Literature Review Monthly. These reviews have been prepared for active foot and ankle surgeons by podiatric residents. Some of the latest are:

Comparison of Surgical Outcomes of Intra-Articular Calcaneal Fractures by Age, from the Journal of Bone and Joint Surgery (American).
Reviewed by Lauren A. Fisher, DPM, Massachusetts General Hospital.

Reliability of MRI Findings of Peroneal Tendinopathy in Patients with Lateral Chronic Ankle Instability, from Clinical Orthopaedic Surgery.
Reviewed by Vikram Thakar, DPM, Massachusetts General Hospital.

Find a variety of abstracts to feed your interests at Scientific Literature Review Monthly.

Foot and Ankle Surgery

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Simultaneous bilateral total ankle replacement (TAR) makes severe degenerative bilateral ankle osteoarthritis manageable for patients, according to a study by Swiss orthopedists presented at the 2011 Annual Meeting of the American Academy of Orthopedic Surgeons. Researchers prospectively enrolled 23 consecutive patients in their study between June 2001 and March 2008, all of whom underwent simultaneous sequential bilateral TAR; this group was compared to 46 patients who underwent unilateral TAR. Both groups' results were compared via the Visual Analog Scale (VAS) for pain, SF-36 instruments, and AOFAS hindfoot score. Postoperatively, researchers followed up with both groups at four months, one year and two years. Postoperatively, all patients experienced a significant pain relief, however the patients with the unilateral TAR were in less pain at four months follow-up, but not at one or two years. VAS scores at four months were 2.2 and 1.6 for the bilateral and unilateral groups, respectively. Also at four months follow-up, the unilateral TAR patients had higher AOFAS hindfoot scores, but the differences between the scores were only statistically significant at this time point. In addition, some range of motion differences existed between the groups and SF-36 scores were slightly lower in the bilateral group, but only at the four-month follow-up.



New research suggests that arthroscopic ligament reconstruction for chronic lateral ankle instability, using suture anchors, can effectively return patients to preinjury function levels. Researchers wrote that the technique is minimally invasive and could be a reasonable alternative to other open surgical procedures for chronic ankle instability. The study retrospectively evaluated the clinical outcomes of arthroscopic repair using a bioabsorbable anchor with two sutures. Investigators evaluated the results of 28 ankles from 28 patients treated with arthroscopic anterior talofibular ligament repair using bioabsorbable anchors with a FiberWire and TigerWire suture placed on the fibula. Patient evaluation used the AOFAS hindfoot ankle score and stress radiographs. Mean score was 92.48 at last follow-up compared to a mean score of 60.78 before the procedure. Researchers noted a 14-percent complication rate, including three cases of portal site irritation and one of superficial infection. All patients returned to their previous activity level, and despite some minor complications, clinical results were generally positive.



Researchers recently completed a study to evaluate the prevalence and location of heterotopic ossification after primary total ankle arthroplasty. The study also sought to determine predisposing factors, effects on clinical outcomes, and a method of classification. The study included 80 ankles in 80 patients with a primary total ankle arthroplasty who were followed for a mean of 31.9 months. Results showed that 20 (25%) of the ankles demonstrated postoperative heterotopic ossification, most of which was in the posterior aspect of the ankle. Eight patients had symptomatic heterotopic ossification, and two of them needed surgical resection because of intractable pain. Heterotopic ossification was associated with significantly longer operative times, less postoperative motion, and lower AOFAS ankle-hindfoot scores at months 6, 12, and 24 of follow-up. Investigators concluded that the prevalence of heterotopic ossification after primary total ankle arthroplasty is considerable.

Practice Management

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A survey commissioned by a congressional agency last year identified 756 concierge medical doctors in the United States, up from 146 in 2005. Concierge medicine is expanding as more physicians, as well as patients, tire of "assembly-line primary care." Critics are worried that more doctors will follow as insurers and government payers cut fees and handcuff providers with regulations.



The Patient Protection and Affordable Care Act requires Medicare to include an "assessment of patient experience and patient, caregiver and family engagement." Industry experts say Medicare will likely integrate that measurement into its pay formula for physicians by 2015. Many medical practices are already asking patients for feedback, either by hiring a vendor or by conducting the survey themselves. Some practices and vendors are using a survey instrument developed by the Department of Health and Human Services for physician offices, called the Consumer Assessment of Healthcare Providers and Systems Clinician & Group survey, or CG-CAHPS, while others are developing their own questions. Practices are also conducting surveys both online and on paper. Whatever format and questions a practice chooses, they should aim to make the survey as brief as possible while still trying to elicit meaningful responses. Keeping questions the same over time may be advisable, as it will help track performance. Asking questions chronologically, starting with when patients make an appointment or arrive, how long they had to wait, to how staff treated the patient, may improve recollection and accuracy.



A new study by the Medical Group Management Association (MGMA) discusses issues faced by physicians seeking to deploy EMRs (electronic medical records) or EHRs (electronic health records). Of the medical practices surveyed who already adopted EMRs, 80.1 percent said they plan to use incentives available through the HITECH Act. But only 13.6 percent said they are able to meet the 15 core criteria for eligibility to receive incentive payments. Interest in qualifying for EHR incentives was strong among the respondents who currently use paper medical records, with 28.8 percent indicating they were in the process of selecting an EHR system, according to MGMA. The study also found that 72 percent of electronic medical record owners expressed satisfaction with their overall systems. However, they were divided over their ability to increase physician productivity, with 26 percent reporting an increase in productivity, 20.6 percent indicating a decrease, and 42.9 percent reporting no change in productivity. The MGMA report also found that, "Interestingly, independent medical practices were more likely to have a fully implemented and optimized EMR than their peers owned by hospital systems." At Susquehanna Health in Williamsport, Penn., hospital leadership worked a physician champion to find ways to enhance their EMR, and "all of a sudden there was engagement," says Steve Johnson, CEO of Susquehanna Health.

Health Policy and Reimbursement

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On April 20, the U.S. Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to revise Medicare payment policies and hospital rates for Fiscal Year (FY) 2012. Proposals detailed in the rule would help substantiate the Obama Administration's efforts to reform the healthcare delivery system by improving care quality and patient outcomes, addressing long-term healthcare cost increases and supporting the goals of the recently announced Partnership for Patients. The proposed rule would update payment policies and rates for acute-care hospitals remunerated through the Inpatient Prospective Payment System (IPPS) and hospitals paid under the Long Term Care Hospital Prospective Payment System (LTCH PPS). The proposed rule also would expand the Hospital Inpatient Quality Reporting Program (IQR) to focus more on patient outcomes and care quality and set the framework for a new quality reporting rubric that would apply to hospitals compensated under the LTCH PPS.



The "meaningful use" reporting period for electronic health records (EHRs) has begun, and hospitals and doctors can now submit data to receive reimbursement payments. Ninety days of data must be collected and submitted to the Centers for Medicare and Medicaid Services, and those facilities that already have had EHRs for some time will be submitting their data on the first day. Experts say most facilities should wait until they are certain they are ready, staff is prepared and everyone is on board to follow the plan before submitting data. Otherwise it is best to wait until 2012 when new criteria is released, though in 2013, reimbursements will decline. Most healthcare providers must have EHRs installed by 2015 when the incentives are replaced by penalties.

Medicine, Drugs and Devices

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A study published in the Archives of Surgery found that surgeons who drink heavily have difficulties performing in the operating theater the following day, even if they do exhibit apparent sobriety. The research involved treating six laparoscopic surgeons to dinner in which they were instructed to drink until they felt intoxicated, and then assessing their surgical skills in a virtual reality environment the next day at 9 a.m., 1 p.m., and 4 p.m. Each time their skills were worse than they had been in a baseline evaluation, with the surgeons committing more errors and being less efficient at employing diathermy to burn tissue. The researchers suggest that "given the considerable cognitive, perceptual, visuospatial, and psychomotor challenges posed by modern image-guided surgical techniques, abstinence from alcohol the night before operating may be a sensible consideration for practicing surgeons."



Numerous medical mistakes take place because of poor communication through botched handoffs from one physician to another. Statistics show that 80 percent of adverse events in hospitals involve communication problems between healthcare professionals. Medical professionals could learn to improve handoffs by studying how the Navy handles handing off posts on vessels. "I would sign out the issues and events that happened on my watch the same way each day," says Doug Bonacum, a former Navy submariner and now the vice president of safety management at Kaiser Permanente. "Anybody who assumed my post would do it the exact same way to their relief as well. In medicine, if I follow three different doctors around on three different days, I'll see three different ways of signing out patients." Doctors could also learn how to improve handoffs by observing nurses changing shifts. Nurses are largely off limits during a shift change, dedicating themselves to relaying information, and at Kaiser nurses have started signing off at a patient's bedside so patients and their families can hear the plan and ask questions.