News From ACFAS

---

Tomorrow is the deadline to volunteer to serve as an ACFAS committee member, Clinical Consensus Statement panelist or Scientific Literature reviewer. Don’t miss your chance to help the College shape the future of our profession in 2020. If you would like to volunteer, visit acfas.org/volunteer to apply.
Want to shape the content and format of the College’s CME programs? Respond to our triennial CME Survey by this Sunday night, November 3.

Your responses will be kept confidential but will make a lasting impact ensuring the next three years of educational offerings are geared to your needs.

A reminder was sent via email from ACFAS on October 28 with a unique link to your survey. You might win one of six $100 American Express gift cards! As we begin preparing for ACFAS 2020 in San Antonio we’d like to ask Residency and Fellowship Directors for their cooperation when hosting residency program reunions, fellowship dinners and other ancillary meetings during the conference.

ACFAS will be hosting the Resident and Student Networking Event and Premier Connection opening reception on Wednesday, February 19. As both are official ACFAS activities, we kindly request that no other events held on February 19 start before 7:30pm.

We thank you in advance for your cooperation. We look forward to seeing you in San Antonio for another extraordinary ACFAS program! Visit acfas.org/sanantonio for more information on this year’s conference. You won’t want to miss all the Exhibit Hall has to offer at ACFAS 2020 February 19-22 in San Antonio. With more than 140 exhibitor companies and 150,000 square feet of exhibits, the Exhibit Hall is the place to be!

Come by to discover the newest services from 140+ companies, participate in interactive product demos, check out the posters during the Grand Rounds from 1-2pm, speak with authors and network with colleagues. You can also check out the HUB theater designed to provide practical learning for practically everyone or stop by the Job Fair to search for your next job or new hire.

Visit acfas.org/sanantonio to find out what else you’ll find this year at ACFAS 2020 to make the most of your conference experience!

Foot and Ankle Surgery

---

The study investigated whether the presence and amount of effusion in the tibiotalar and talocalcaneal joints are associated with an increased risk for sever structural injury in ankle sprains. A total of 261 athletes with acute ankle sprains were assessed on magnetic resonance imaging (MRI) for the presence and amount of effusion in the tibiotalar and talocalcaneal joints, as well as for ligamentous and osteochondral injury. Patterns of injury severity were defined based on lateral collateral ligament, syndesmotic and talar osteochondral involvement.

The presence and amount of effusion (grades 1 and 2) were considered as risk factors when using conditional logistic regression to assess the risk for associated severe injuries (syndesmotic ligament rupture and talar osteochondral lesions), while the physiological amount of fluid (grade 0) was considered as the referent. The risk for partial or complete syndesmotic ligament rupture increased more than eightfold for ankles exhibiting large (grade 2) effusion in the tibiotalar joint, and the presence of any degree of effusion in any of the joints was associated with an increased risk for severe talar osteochondral involvement.


The investigation examined the use of three-dimensional (3D) printed bone models representing the Lauge-Hansen classification in educating podiatric medical students on the evaluation of and treatment protocols for ankle fractures. Tomography scans of subjects with actual rotational ankle fractures representative of the classification were identified and extracted into a format compatible with a 3D printer. The models are approximately 20 centimeters in height and made of ivory-colored plastic. These were implemented into the curriculum of a traumatology course with third-year podiatric medical students through a hands-on workshop. Students expressed high levels of satisfaction with the use of these models, and most recommended continuing to use them in the curriculum. The investigation indicates that 3D technology within podiatric medical education is feasible and offers high levels of student satisfaction.


The study aimed to determine whether variation in foot rotation relative to camera position affects the reliability of measurement of hindfoot alignment on radiographs, and to define a "safe zone" where measurement of the alignment axis is not affected by foot rotation. Twenty healthy volunteers were recruited and their double-sided lower-leg weight-bearing computed tomography (CT) was acquired. Weight-bearing was simulated by providing axial compression force equal to the weight of the volunteers. The scans were uploaded into custom three-dimensional analysis software to create digitally reconstructed radiographs, and a coordinate system was determined to define the neutral position of the leg for each CT examination.

Rotation about the z-axis of this coordinate were reconstructed for the leg between 30 degrees of endorotation and 45 degrees of exorotation, and the relation between the observed alignment axis and foot rotation was determined. Per 5 degrees of leg rotation, the alignment axis translated with a mean of 6.86 percent (SD ±13.1). There was no significant difference in position observed between 10 degrees of endorotation and 10 degrees of exorotation compared to the neutral ankle position. The study finds that the "safe zone" for imaging the hindfoot alignment axis is between 10 degrees endorotation and 10 degrees exorotation of the foot.

Practice Management

---

Many electronic health record (EHR) systems suffer from poor usability and interoperability. To address this, the Office of the National Coordinator for Health IT has proposed rules that it hopes will change how doctors interact with their EHRs and engage with patients by giving them access to their data. The changes focus on providing a set of standards that will introduce apps to the EHR ecosystem to enhance its usability and interoperability. This will require an application programming interface (API) or a shared set of standards on how information is exchanged. APIs allow data to flow seamlessly regardless of their structure or what database they use, improving interoperability in ways that could meaningfully impact doctors, making needed information less complicated to obtain. However, industry experts note that APIs are not the only way to achieve these goals, and they come with their own set of problems.

Practices will have to finance technology upgrades, which may punish smaller practices, and it may be challenging to suit APIs for workflows that vary by specialty. Moreover, API security and privacy is somewhat under-formed as it is currently very reliant on developers and vendors. Once patients agree to the terms of any app and information flows into it from the EHR, that data may be used for a wide variety of purposes, even monetized, as it will no longer be covered by HIPAA or any federal privacy laws. For example, an employer could offer a health app and use it to access their employees' health records. Experts call for a developer certification process that includes commitment to privacy and security, alongside clear statements of what the developer plans to do with collected EHR data.


A recent report by the National Academy of Medicine finds that as many as half of the country's doctors and nurses experience substantial symptoms of burnout. The committee found that burnout is experienced by 35 to 54 percent of nurses and doctors and by 60 percent of medical students. Symptoms of burnout include emotional exhaustion, cynicism, loss of enthusiasm and joy in their work and increasing detachment from their patients. The problem has been linked to higher rates of depression, substance abuse and suicide. High rates of burnout create risks for patients and lead to worker absenteeism, turnover and billions of dollars in losses to the medical industry each year. These findings highlight that the issue of burnout is systematic and will require fundamental changes to fix. High burnout rates are a byproduct of an increasingly dysfunctional healthcare system, as workers face long hours, mounting paperwork, bureaucratic hurdles, fear of malpractice lawsuits, unsustainable workloads and insufficient resources.


Healthcare practices across the country are struggling to find experienced employees. Practices may benefit from hiring younger employees, namely Generation Z, which refers to those born in or after 1995. Members of Generation Z tend to exhibit strong work ethic, a collaborative attitude and a high level of comfort with technology. Their ability to smoothly navigate virtual and offline experiences means that members of Generation Z may be able to interact with patients of all ages in the formats they prefer and manage information from a variety of sources. Moreover, many of these young adults value authenticity and want to make an impact on the world around them, and their general beliefs align well with healthcare work.

However, members of Generation Z are also more interested in financial security and stability than previous generations, and many struggle with unprecedented levels of college debt. Recognizing Gen Zs' need for financial stability without crippling debt, many leading companies have announced that they no longer require college degrees for many positions. Physician practices can capitalize on this by developing positions that do not require degrees, help employees earn certifications and provide on-the-job training and mentoring. This might include new types of training in softer skills, as a recent survey finds that 37 percent of Gen Z respondents worry that technology is weakening their ability to maintain strong interpersonal relationships and develop human skills. However, Gen Z employees' comfort with technology can also help older employers modernize their practices and become more tech- and social media-savvy.

Health Policy and Reimbursement

---

The growth of telehealth services carries greater regulatory risk, especially with differing state laws on telehealth and the relationships between state regulations and federal policies. Policies concerning delivery, provider credentialing and informed consent can shed light on the telehealth situation. Although new delivery channels allow telehealth providers to better personalize care, state and federal reimbursement policies vary widely. The U.S. Centers for Medicare and Medicaid Services (CMS) finalized a rule allowing Medicare Advantage plans to cover additional telehealth services as basic benefits to instill flexibility in managing future innovations. State laws have transitioned from limiting telehealth use to rural or underserved areas with respect to state Medicaid programs, but still limit qualifying originating sites and often exclude beneficiaries' homes; this neutralizes both reimbursement for remote beneficiary management and the convenience of telehealth.

Medicare does not categorize remote management as telehealth, and so is not subject to originating site restrictions, and CMS has proposed reimbursement codes for remote monitoring. Meanwhile, provider credentialing is a state-by-state affair that runs counter to telehealth's goal of removing geographic barriers to healthcare. Finally, almost 40 states have passed telehealth-related informed consent requirements, and a number of mandates also require providers to inform beneficiaries that they may opt to receive services in person.


Officials in several states are pursuing legislation to preserve some of the Affordable Care Act (ACA) if a federal appeals court strikes down the law. Lawmakers in several states, including Louisiana, Nevada, New Mexico and California, have passed bills or are reviewing action aimed at dealing with the fallout if the ACA is overturned. Colorado is pursuing the creation of an insurance plan, similar to a so-called public option, that would provide insurance to people on the individual market. The state would set the rates, which could help lower premium costs if the ACA ends. Meanwhile, under legislation signed by Gov. John Bel Edwards, Louisiana is seeking input on a replacement plan that would provide some coverage to people with pre-existing health conditions, said Frank Opelka, deputy commissioner for life, health and annuity.

The legislation calls on the state insurance commissioner to establish a "high-risk pool," where insurers receive subsidies for covering people with expensive medical conditions who are locked out of health insurance. "States should certainly be thinking about contingency plans," said Nicholas Bagley, a professor at the University of Michigan law school, noting that "coming up with reasonable contingency plans will take time."


The U.S. Centers for Medicare and Medicaid Services has announced that the average premium for a "benchmark" silver plan on HealthCare.gov for a 27-year-old will drop by 4 percent in the 2020 coverage year, compared to a 1 percent drop from 2018 to 2019. Overall, 27 of the 38 states on the exchange will see decreases in the benchmark premium, including double-digit declines for Delaware, Nebraska, North Dakota, Montana, Oklahoma and Utah. Only two states will have a single health insurance plan in 2020, down from five states last year, and the average enrollee will have 3.5 issuers available in 2020, up from 2.8 issuers last year. In addition, 20 more health insurance companies will participate in the Federal Health Insurance Exchange, bringing the total number of issuers to 175 from 132 in 2018.

Despite the expanded number of health plans, Affordable Care Act plans remain unaffordable for most people without a subsidy. Unsubsidized enrollment across the country declined by 2.5 million people between 2016 and 2018, and 85 percent of the additions to the uninsured in 2018 occurred among people with income higher than 300 percent of the federal poverty line.

Medicine, Drugs and Devices

---

Stephen M. Hahn, a radiation oncologist and chief medical executive at M.D. Anderson Cancer Center in Houston, is President Trump's choice to be the next commissioner of the U.S. Food and Drug Administration (FDA), insiders say. Hahn would replace Acting FDA Commissioner Ned Sharpless, whose term expires November 1. Sharpless took on the position following the departure of Scott Gottlieb in April.


New technologies appear to be driving the stethoscope into obsolescence, including handhelds that use ultrasound, artificial intelligence (AI) and smartphone apps. Advocates say these devices boast as much ease-of-use as stethoscopes, allowing doctors to monitor the body in motion and to visualize leaky valves and other problems. Northwestern Medicine's James Thomas said, "Some recent studies have shown that graduates in internal medicine and emergency medicine may miss as many of half of murmurs using a stethoscope." For example, Butterfly Network's Butterfly iQ device, which went to market last year, will soon receive an AI upgrade, so users can position the ultrasound probe and read the image. Meanwhile, Northwestern Medicine is testing technology from smart stethoscope maker Eko, involving AI algorithms to better detect heart murmurs, trained on recordings of thousands of heartbeats.


United Parcel Service (UPS) announced agreements with healthcare groups to use drones for delivering medical samples and supplies. The drones will carry cargo on hospital campuses at the University of Utah and elsewhere, and UPS also agreed with CVS Health to assess drone-based home delivery of prescriptions and other products. These are the first such pacts announced since the U.S. Federal Aviation Administration approved operation of commercial drone flights via UPS' Flight Forward subsidiary. UPS also is readying a drone logistics project with Kaiser Permanente, to evaluate building-to-building supply transfer via drone at Kaiser's 39-hospital network. UPS said medical supplies are very well-suited to drone delivery, because they are lightweight and tend to be uniform in size.