News From ACFAS

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Profiles and position statements of the four candidates nominated for the ACFAS Board of Directors are now posted at acfas.org/nominations. Voting opens Nov. 30, and each eligible voting member will receive an email with a unique link to the election website. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without a valid email address will receive instructions on how to log into the election website and vote by U.S. mail. There will be no paper ballots.

Two three-year terms and one two-year term will be filled by election. The ballot appearance is prescribed in the bylaws. Eligible voters may cast one, two or three votes on their ballot. Regular member classes eligible to vote are Fellows, Associates, Emeritus (formerly Senior) and Life Members.
Look beyond the ordinary to elevate your skills, build new connections and revitalize your practice. Register for ACFAS 2016 in Austin and choose from more than 40 scientific sessions, including hands-on workshops, across the spectrum of foot and ankle surgery. Unlimited networking opportunities and more than 140 exhibits will provide the tools, insights and inspiration needed to take your learning to the next level.

Visit acfas.org/austin for full details and to save on registration and hotel accommodations.
In honor of National Diabetes Month, ACFAS has released a new infographic, The Dos and Don’ts for Diabetic Foot Care, as part of a nationwide ACFAS public relations campaign.

This latest free promotional tool is available for download in both English and Spanish in the ACFAS Marketing Toolbox and on FootHealthFacts.org. Share the infographic with your patients and post it to your social media channels to streamline your patient education efforts. You can also print the infographic and hang it in your exam and waiting rooms.

More infographics will be added to the Marketing Toolbox throughout the year. Refer to the Infographics section at acfas.org/marketing for new releases and updates.
Have you had an interesting yet perplexing case? Share it with your colleagues in the Doctors’ Lounge at ACFAS 2016. This relaxed interactive session features a panel of clinicians who will discuss your case with you and an audience of your peers.

Visit acfas.org/austin to download and complete the Doctors’ Lounge Case Form and email it to Marilyn Wallace by Dec. 11. If your case is selected for presentation, you will be notified after a formal review of all submissions.
ACFAS has three exciting opportunities for foot and ankle surgeons to share their expertise on surgical quality measures and medical device technology.

1. The National Quality Forum is soliciting nominations for a standing committee to evaluate new surgical measures and review previously adopted measures. The measures will address surgical events (pre-, intra- and postsurgical care), use of perioperative medications and adverse surgical outcomes.
    
2. The U.S. Food and Drug Administration is seeking College members to provide outside expertise and give clinical and scientific viewpoints on medical device development.
    
3. The College is identifying volunteers to serve on the Credentialing and Privileging Advisory Team (CPAT). Volunteers should be well versed in privileging and credentialing issues in a variety of healthcare settings. CPAT volunteers will assist members with their credentialing questions.

For more information on these opportunities, including expertise requirements, time commitments and nomination materials, contact Sarah Nichelson, ACFAS director of Health Policy, Practice Management and Research, at sarah.nichelson@acfas.org.

Foot and Ankle Surgery

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Researchers recently analyzed the reliability of a new angle called the "angle to be corrected" (ATC) for hallux valgus angular measurements, compared against the intermetatarsal angle (IMA). Twenty-eight symptomatic hallux valgus patients were observed. The IMA average value was 13.6 degrees while the average value for the ATC was 8.9 degrees. No difference existed between observers for the ATC, but there was significant difference between two observers for the IMA. The researchers concluded that the ATC was at least as reliable as the IMA for measurements and could be considered a better option when deciding between different operative treatments.


A recent study analyzed the changes in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) to determine factors affecting restoration of alignment. Researchers observed 119 patients who underwent TAA using the Hintegra prosthesis, 63 of whom had anterior displacement of the talus before surgery, 49 of whom had alignment in the normal range and eight who had posterior displacement of the talus. An anteriorly translated talus was restored to normal position in most patients. Restoration of alignment was significantly influenced by the posterior slope of the tibial component, and researchers suggested that surgeons performing the procedure should insert the tibial component at close to 90 degrees relative to the tibia.

Practice Management

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Many people believe that electronic health records (EHRs) jeopardize patient interactions, with 70 percent of physicians complaining about decreased face-to-face time in a 2014 survey. Dr. Aaron Neinstein believes that the benefits of EHRs far exceed the drawbacks and recently penned eight "best practices" to adopt with the EHR to enhance relationships with patients:

1. Ensure proper setup of the exam room. Make sure the chairs, monitor and keyboard allow good eye contact. Try to position everything so that you need not swivel your neck.
2. Use a widescreen monitor. This will allow you to share information with the patient more effectively.
3. Let patients see your screen. If patients are able to share in the experience, they will get more out of it. In addition, it is possible for patients to point out the occasional error in their charts.
4. Get a quiet keyboard. Noisy keyboards can be disruptive for both you and the patient. The flow of conversation improves with a quiet keyboard.
5. Make sure that the EHR is cued to the right page before you sit down with the patient in the exam room. The first few moments of interaction are critical, and if you are spending them firing up your machine, that opportunity is lost.
6. Work with your healthcare organization to determine what makes a good note. Determine what makes "discrete data" and what makes "free text." A good note strikes some balance, capturing crucial data while allowing room for narrative.
7. Invest in an "optimization" half-day. If you have used your system for a few months, spend four hours one day tweaking it and learning how to make it more efficient.
8. During the patient visit, stop typing and look your patient in the eye. There is no substitute for 100 percent focus on a patient, and establishing eye contact is the best way to do that.

Not all small practices have handled the ICD-10 transition as well as James Legan's team. That is because Legan began planning for ICD-10 way in advance and was not worried about any troubles when Oct. 1 rolled around. Legan upgraded his server to a cloud-based service six months before the deadline, meaning that his electronic health record (EHR) system automatically upgraded to make its ICD-9 codes more specific. This does not mean that every code easily translates, but Legan says it certainly makes it easier. But Legan did more than just upgrade his EHR. He printed out common ICD-9 codes and cross-walked them to ICD-10, printing the information on a laminated sheet. He hired an expert to address his team at the practice. Despite the issues that small practices are reportedly having with implementation, Legan says that his practice's size has actually helped his preparation. "The advantage we have as a small practice, is each doctor can pick the tools that work individually for us … we're linked under a [practice management system], which works well with the clearinghouses," he said. He recommends that any practice feeling the squeeze of ICD-10 should use his laminated sheet method and properly communicate with staff.


A new report highlighted three organizations, all of different types and sizes, and analyzed how they used technology to invest in population health and improve care and outcomes. The first organization, Orlando Health, created a clinically integrated network by implementing technology that the entire eight-hospital system could use as a single reference source for patient data. It allowed them to target patients and contact them when necessary, as well as inform them of care gaps and other issues. Orlando Health was able to send appointment reminders to 300,000 patients, which resulted in a 22 percent increase in patients who responded to the messages and sought care. At Northeast Georgia Diagnostic Clinic, it was difficult to manage 50,000 patients with limited resources. The clinic used a platform to build patient registries based on chronic conditions to identify care gaps and perform outreach. It helped identify 29,000 patients with at least one care gap and contacted more than 15,000 patients about follow-up care. Finally, at a small independent practice in West Virginia, administrative director Terry Coleman used population health management technology to expand the number of patients it reached with daily emails and reminders. Following implementation, 82 percent of patients 65+ had annual wellness exams, and adolescent wellness exams increased by 146 percent.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) have released several final rules for payments to physicians and hospitals, including information on the two-midnight rule, shared savings and advance care planning. The agency said the guidelines for the two-midnight rule emphasize the importance of a physician's medical judgement. CMS also modified the Medicare Shared Savings Program by adding a quality measure for statin therapy. CMS will reimburse doctors who discuss advance directives, hospice care and other end-of-life issues. Lastly, a new payment system was finalized to replace the sustainable growth rate formula, and it will be formally implemented in 2019. "These rules continue to advance value-based purchasing and promote program integrity, making Medicare better for consumers, providers and taxpayers," said CMS Acting Administrator Andy Slavitt.


One of the main goals of the Affordable Care Act is to reduce excess spending, but an increase in malpractice lawsuits could become an unintended consequence. A study published in the British Medical Journal tracked 24,000 Florida physicians over nine years and found that in six specialties, doctors who spent the most on patients had the lowest risk of being sued. For years, doctors have reported practicing defensive medicine, which includes things like unnecessary imaging scans and blood work. The study suggests that defensive medicine may reduce lawsuits. For example, doctors who spent nearly $40,000 per hospital admission had a 0.3 percent chance of getting sued. The physicians with the lowest hospital charges were five times as likely to be sued.


A recent survey aimed to determine the challenges that hospitals with fewer than 400 beds are experiencing during the ICD-10 transition. Survey leader Tom Grove noted that it is too early to gauge revenue cycle effects, but significant transitional issues are still evident. First, inadequate documentation improvements among physicians appear to be an issue among smaller hospitals and for many, their greatest challenge. Several educational offerings and training sessions have seen little participation, either because training lacked proper emphasis or because hospital physician staff opposed the support. The survey found that at least some of these smaller hospitals are working to catch up, but immediate affordable solutions are not easy to find. Other areas of concern include health information management. Some hospitals that took strong approaches to training report productivity decreases of only 10 percent while hospitals that spurned training are facing decreases upward of 50 percent. In addition, some smaller hospitals are still receiving patients with ICD-9 coded diagnoses for testing performed after implementation. Experts suggest that this is not the time to relax. Hospitals must quickly address the issues affecting their processes and consider new support and training reinforcement tactics.

Medicine, Drugs and Devices

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A group of scientists has released a paper arguing that researchers need to better utilize current methods and tools for data synthesis to consolidate data and glean better understanding. Researchers typically pool the same kind of data, but different study and data types have distinct strengths and weaknesses. Therefore, it is important to find a way to bring together multiple, extremely diverse data sets. Scientists need to work out why, when and how to combine diverse data. In addition, there needs to be agreed ways to capture and represent information on potential sources of bias. Methods to deal with bias must be incorporated into new analytical systems to guide decision-making in healthcare. Major granting agencies should invest in research methods programs, which could lead to a new type of analyst who can combine diverse data types appropriately. Eventually, these shifts in research ideology could lead to scientists having enough knowledge to prevent cancer and even develop new cancer therapies. In this case, data would need to be synthesized from genomic, behavioral and environmental factors to get a comprehensive picture of all known information. No one-model-fits-all approach exists, but the proliferation of massive, diverse data sets means that new methods to understand data must be discovered.


Researchers at Northeastern University have developed a new approach to 3D printing that could radically shape how medical devices are made. The technology allows for new devices that are more individualized than previously possible. Instead of predesigning a material, the new method uses magnets to reinforce the mechanical strength and suit the needs of an individual device; this in turn could end problems associated with size requirements and clinical enrollment issues. Pediatric medicine stands the most to gain since a child's size, physiology, development and growth rate are difficult to take into account, especially because it is not enough to take an adult-sized device and make it smaller. The team of scientists behind the breakthrough said the next step is to use calcium phosphate fibers and biocompatible plastics to design and print surgical implants.


The Library of Congress has proposed a final rule that could affect medical device security. The rule adopts exemptions to a provision of the Digital Millennium Copyright Act and permits "good-faith security research" on computer programs that operate on certain lawfully acquired products. Most importantly, the proposed rule would allow "circumvention of [technical protection measures] protecting computer programs in medical devices designed for attachment to or implantation in patients and in their corresponding monitoring devices." This has raised objections from many organizations who claim that patients have an "inherent right" to access their own data. In addition, some experts warned that data gathered through security research could be used by hackers to access highly regulated devices. These devices could jeopardize a patient’s privacy and security information because they are connected to electronic medical records. The exemptions will go into effect in one year.


Patients with rheumatoid arthritis can experience improved symptoms when using tocilizumab when received in combination with methotrexate or as monotherapy. A new study shows that remission was achieved after 24 weeks in 45 percent of patients who received 8 mg/kg tocilizumab plus methotrexate compared with 15 percent of patients who received a placebo. In 52 weeks, 49 percent of patients in the first group had remission compared to 20 percent in the placebo group. Adverse events were similar across all groups.