News From ACFAS

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Have you taken a moment to dive in and explore the new acfas.org? Navigate the new frontier of this re-vamped website and take advantage of the many improvements we’ve made, including the re-naming and re-structuring of the navigation so you can find what you’re looking for faster. Also, we now have individual “Centers” for students, residents and members – with their own home pages filled with pertinent topics specific to each audience – as well as these other key features:

• New, Interactive Education Calendar
• An Enriched Marketing Toolbox to Help Market Your Practice
• Direct Links to the Latest JFAS Articles on the Home Page
• Enhanced Search Feature to Find the Content You Need
• Mobile Friendly Optimization for Viewing on Your Smart Phone
• Twitter Feed on the Home Page

Take a moment to test the new website for yourself and see how easy it is to find your way around the valuable information the College has to offer! In order to support those unmatched residents who have yet to find a placement within a program, the ACFAS Membership Committee has created a new “Student-Transitional” category of membership and offers graduated students a one-year complimentary transitional membership. In previous years, those who remained unmatched were not provided access to ACFAS member benefits until they found a match and were able to join as a resident.

Graduated students who are without a residency match can benefit from association with ACFAS, through electronic access to the Journal of Foot & Ankle Surgery, student pricing to all ACFAS educational offerings, and linkage to a network of proven leaders who can be available to them in their search for a match. The one-year complimentary transitional membership allows them to stay as part of the ACFAS community, receive the many benefits of membership for the next 12 months, keep this association on their résumé, and hopefully help them to bridge the gap to finding a placement in the next 12 months.

If you are an unmatched residency placement or know of someone who could benefit from this transitional status with ACFAS, please contact the Membership Department at (773) 693-9300 or via email at membership@acfas.org for more information and assistance. Listen to the latest ACFAS podcast on all things Achilles Tendinopathy. The panel in this multifaceted, detailed discussion touches on the many variables associated with Achilles tendinosis as it progresses into full scale tendinopathy in patients. Some of the conversations within this podcast include:

• How do you diagnose Achilles tendinosis?
• How often do you see additional pathologies superimposed over Achilles tendinosis?
• Is imaging important early on or do you rely on more basic radiography and clinical exams?
• How does obesity factor with this, and how do you discuss this with obese patients?

...and many more. Want to hear the rest? Listen to this and other valuable ACFAS podcasts today.

Foot and Ankle Surgery

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A recent study examined the use of perforator-based thoracodorsal chimaeric flaps in treating severe foot and ankle defects. Surgeons reconstructed an extended circumferential defect of the ankle with an exposed heel using a chimaeric thoracodorsal perforator flap with a serratus muscle flap. Surgeons transferred the skin flap on the dorsal foot, while the serratus anterior muscle was transferred on the exposed heel. No complications were seen during post-operative recovery, and the patient was able to begin full weight bearing after three months. Natural shape and walking function were achieved 12 months after the reconstruction.


Researchers in Germany have performed a study of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons, which are typically used in reconstructive foot and ankle surgery. The study had three goals: to integrate the conflicting results of previous anatomical studies of the FHL and FDL tendons, create a thorough classification system, and analyze the position of the tendons' interconnections relative to the surgically-relevant landmarks.

Researchers examined 60 embalmed feet and observed a proximal to distal connection from the FHL to FDL in 95 percent of the feet. A proximal to distal connection from the FDL to the FHL tendon was seen in 3 percent of the feet, while a crossed connection was observed in 30 percent of the specimens. Finally, researchers found that the average point of branching of the FHL and FDL tendon was 5.3 centimeters and 4.6 centimeters distal to the medial malleolus, respectively. The classification system developed by researchers was able to accommodate all of the variations that were seen in the feet.

The study concluded that the presence of a proximal to distal connection from the FHL to the FDL could contribute to the residual function of the lesser toes following FDL transfer. Researchers also noted that having an exact knowledge of the anatomy of the crossing of the FDL and FHL tendons in the plantar foot is vital in tendon harvesting, reducing morbidity, and explaining possible postoperative functional loss.

Practice Management

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Experts say that electronic health record (EHR) systems contain a great deal of information that doctors can use to help improve their practices. For example, the data contained in EHRs can help practices make improvements in the way care is provided to patients. According to Beth Shindele, the director of improving health for populations and communities for Quality Insights of Delaware, doctors should begin this process by first creating a full practice profile by running queries on certain patient populations. This profile can then be used to determine which patient populations the practice should focus on as well as the measurements that might need improvement. Data from EHRs can also be used to identify improvements in the way practices are operated from a business standpoint, and can help doctors identify opportunities to participate in new payment models. Experts say whatever changes practices make as a result of an analysis of EHR data should be implemented gradually in order to keep staff motivated. Benchmarks of success should be set, experts say, and when those goals are reached the practice should move on to its next objective.


The Office of the National Coordinator for Health Information Technology has chosen 28 doctors and medical support staff to look for ways that electronic medical records (EMRs) can improve patient outcomes. One of the doctors who was chosen was Dr. Jennifer Brull of Prairie Star Family Practice in Plainville, Kan. Brull says that many doctors are not aware of the benefits of using EMRs, including easier tracking of an individual's records, ensuring that patients receive appropriate treatments, and making it easier to meet a patient's particular needs during an appointment. Brull and the other doctors and medical support staff who have been chosen by the Office of the National Coordinator for Health Information Technology want to educate doctors about the benefits of using EMRs, though it is unclear how this education process will happen. The doctors and medical support staff who were selected for the project will only have a year to work together, and they will need to maintain their own practices during that time.


The Centers for Medicare and Medicaid Services (CMS) will not ask its Medicare administrative contractors (MACs) to test their claims processing systems with outside organizations ahead of the implementation of ICD-10 next year, says Cathy Carter, the director of the business applications management group in CMS' Office of Information Services.

Carter's remarks came at a congressional hearing on June 18, and were partly in response to rumors that CMS had been planning to conduct external end-to-end testing with outside organizations for ICD-10 claims flows. These organizations include claims clearinghouses that work with smaller providers that are less technologically sophisticated as well as larger and more tech-savvy providers that submit reimbursement claims directly to MACs.

But Clark testified during a hearing by the subcommittee on standards of the National Committee on Vital and Health Statistics, a Department of Health and Human Services advisory panel, that there was never a plan in place at CMS to perform tests with providers "all the way through." CMS' decision not to conduct this testing is being met with criticism from Stanley Nachimson, the chairman of the ICD-10 workgroup at the Workgroup for Electronic Data Interchange, who said that the lack of these tests will make it impossible for Medicare to determine if the assumptions it made in its system conversions are accurate. He added that the lack of testing will also result in submitters having no idea if and how their ICD-10 transactions will be processed.

Health Policy and Reimbursement

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Medicare on June 27 altered its Physician Compare website to allow patients to search for doctors more easily. The changes mean that patients can now search for doctors by specialty or by medical condition. The website also features an image of the human body that users can click to find a doctor who can treat the part of the body that requires medical attention. In addition, the website uses Medicare billing information to more reliably identify the locations where doctors are actively practicing. Further changes are coming as the Centers for Medicare & Medicaid Services prepares to comply with a provision of the Affordable Care Act that requires it to publish performance data, including ratings given to doctors by patients, information about the success of the medical interventions provided by doctors, and information about how well doctors follow clinical guidelines for basic care. Quality data for group practices will be added to the site next year, though it remains unclear when ratings will be added for individual doctors. Some of the information provided on the site will also be used in the Physician Value-Based Payment Modifier program, in which Medicare will alter the pay of physician groups and all doctors beginning in 2015 and 2017, respectively.


The Centers for Medicare and Medicaid Services (CMS) indicates that at least four of the 32 Pioneer accountable care organizations (ACOs) have started to notify providers that they intend to leave the program. These four ACOs plan to join Medicare's Shared Savings Program, in which ACOs enter into contracts with doctors and hospitals that do not call for financial penalties for poor performance for the first three years. By contrast, Pioneer ACOs enter into contracts with healthcare providers to bring about savings on patients' medical costs and meet quality targets in exchange for financial incentives. ACOs that fail to meet these goals are also subject to penalties after the second year, which began last January.


There are several indications that the Centers for Medicare & Medicaid Services (CMS) could begin releasing records on Medicare claims payments to individual doctors--records that it has kept secret for nearly 35 years. For instance, a U.S. District Court judge in Jacksonville, Fla., ruled in May that the permanent injunction that was adopted in 1979 to prevent the release of physician-specific Medicare data should be dissolved on the grounds that doctors' privacy concerns are no longer outweighed by the public desire to see the data. That decision recently prompted the Obama administration to release hospital-specific Medicare charges and other data, all of which had previously been kept secret.

But a number of uncertainties regarding the release of Medicare claims payments to individual physicians remain. For example, while the Obama administration has argued that the 1979 injunction should be ended, it remains opposed to the release of the data under a provision of the Freedom of Information Act. That means that the release of the data in question will be delayed while CMS begins a larger legal debate about whether the public interest in releasing the records would outweigh the privacy interests of doctors. The plaintiffs in the lawsuit that resulted in the injunction being overturned could also appeal the court's decision. They have until July 30 to do so.


State and federal officials have a number of tasks that they need to complete before Oct. 1, when the main provisions of the Affordable Care Act take effect. Many of these tasks are related to the launch of the health insurance exchanges in October, which is now less than 100 days away. For example, the Department of Health and Human Services must certify that 17 states will be able to launch their own health insurance exchanges, partner with six states in building exchanges, and construct marketplaces for the remaining states. Officials in states such as Oregon and California have lengthy to-do lists of their own, including holding training sessions for community partners and setting up call centers to answer questions from consumers about purchasing health insurance through the exchanges.


Effective immediately, the Joint Commission has revised element of performance (EP) 5 of the National Patient Safety Goal on surgical site infection prevention (NPSG.07.05.01) to align with the Centers for Disease Control and Prevention (CDC) revised requirements. In February 2013, the Joint Commission placed a moratorium on scoring noncompliance with one requirement of EP 5 (see the February 20 issue of Joint Commission Online). The moratorium (which is no longer in effect due to the revised requirements) was put in place because the CDC no longer required one-year surveillance for procedures in which devices or materials have been implanted during a surgery. Instead, surveillance is now required for either 30 or 90 days following a procedure; the surveillance period is defined by National Healthcare Safety Network (NHSN) procedural codes. The final revised requirement will appear in Update 2 to the accreditation manuals for hospitals, critical access hospitals, ambulatory care organizations, and office-based surgery practices. For free guidance on how to implement NPSG.07.05.01, download the Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections: The SSI Change Project.

Medicine, Drugs and Devices

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A surgeon in Maine who recently became the first person to use Google Glass during a surgical procedure says that the device has "tremendous" potential as a teaching tool for surgeons. Dr. Rafael Grossman wore Google Glass during a procedure to insert a feeding tube into a patient, allowing him to stream video from the device through a Google Hangout. The video feed from the device was also sent to an iPad in the operating room to allow Grossman's colleagues and other viewers to see the procedure from his vantage point. Grossman says that using Google Glass during surgeries offers a number of advantages, including better intraoperative consultations, surgical mentoring, and remote medical education. Meanwhile, Dr. Iltifat Hussain said that using Google Glass during surgery can link doctors in underserved areas with colleagues thousands of miles away, thereby allowing them to collaborate on intraoperative consultations and ask for second opinions during a procedure.


The U.S. Supreme Court issued its ruling on Monday in the case of Mutual Pharmaceutical v. Bartlett, overturning a $21 million award given by a New Hampshire court to a woman who suffered a severe allergic reaction after taking a generic drug made by Mutual. The High Court ruled five-to-four that the award should be overturned because generic drugmakers cannot be sued under state law for adverse reactions in patients who take their products, since federal law supersedes state law claims. The court's ruling also stated that state law cannot run against federal laws on prescription drugs whose design has been approved by the Food and Drug Administration. Consumer advocates are criticizing the decision, saying that it will provide a disincentive for generic drugmakers to monitor the safety of their products and any adverse reactions in the patients who take them.


Post-hoc analyses of the Randomized Controlled Evaluation of Adalimumab in Treatment of Chronic Plaque Psoriasis of the Hands and Feet (REACH) trial have shown that adalimumab is effective in treating these conditions over a 16-week period, regardless of baseline characteristics. Researchers analyzed 72 patients, 49 of whom were given adalimumab while the rest were given a placebo. They found that larger percentages of patients in the adalimumab group achieved the primary endpoint, which was defined as the percentage of patients achieving Physician's Global Assessment of the hands and/or feet of clear/almost clear after 16 weeks, than did patients in the placebo group. Researchers also found that a larger percentage of patients with nail psoriasis who were given adalimumab achieved Nail Psoriasis Severity Index (NAPSI) 50 than patients who were given a placebo after 16 weeks. This improvement in nail psoriasis was related to significant improvements in skin disease and patient reported outcomes. Finally, researchers found that larger percentages of NAPSI 50 responders in the adalimumab group achieved the primary endpoint than did non-responders, and they also experienced greater improvements in erythema, scaling, induration and fissuring, Dermatology Life Quality Index, and pain scores.