News From ACFAS

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The American Medical Association's House of Delegates meeting may have ended yesterday, but their work related to the Scope of Practice Partnership is far from over.

Delegates debated the new CMS regulations on the Conditions of Participation (CoP) for Medicare-funded acute care settings that would allow, among other things, DPMs to hold the chief of staff post on medical staffs, similar to their MD, DO and DDS colleagues. AMA voted to preserve policy that will vigorously defend any changes to MD/DO medical staff authority. ACFAS first identified this issue to the Joint Commission and asked for their support. Also, the AMA Litigation Center noted its ongoing support for the Texas MD-DPM scope of practice battle, citing the fact that DPMs want an increase in scope for all podiatrists, regardless of their training or residency. AMA has supported its Texas Medical Association with over $200,000 and numerous in-kind resources.

In practice news, AMA voted to work to stop implementation of the International Classification of Diseases 10th Revision family of diagnostic and procedural codes unfunded mandate, citing the healthcare industry's already full plate for changes and reforms, including the federal push for physicians to adopt electronic health record systems.
While you’re immersed in learning from lectures, debates, discussions and workshops at the ACFAS 2012 Annual Scientific Conference, don’t overlook the charms of host city San Antonio. The conference site at the Henry B. Gonzalez Convention Center is an easy stroll to a world of choices in dining, music, shopping, natural beauty and cultural history. From glass-blowing to golfing, there’s something for everyone to enjoy in this inviting city with a small-town feel.

Start making your plans today to add to your medical and practice knowledge in the warm heart of Texas. Preconference workshops begin Feb. 29 and the full conference runs March 1–4, 2012. Hotel information, the complete conference program and convenient online registration is available now at acfas.org/sanantonio.

Legal Briefs

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The Michigan Court of Appeals confirmed the protection against disclosure for credentialing and privileging files maintained by hospitals in Johnson v Detroit Medical Center. The court also broadly applied the physician-patient privilege to prohibit disclosure of a physician’s log of procedures even if patient names are deleted. In the case, the plaintiff sought discovery of the hospital’s credentialing file for the defendant physician. The plaintiff also subpoenaed the operative logs listing the dates and procedures performed by the defendant surgeon.

The Public Health Code requires hospitals to "assure that physicians and dentists admitted to practice in the hospital are granted hospital privileges consistent with their individual training, experience, and other qualifications." Unless one of the limited statutory exceptions applies, the materials gathered and evaluations made by a credentialing committee are confidential. The court held that "everything within the file is protected," so that a hospital does not have to justify the protection against disclosure for individual documents.

Foot and Ankle Surgery

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A longitudinal study was held to investigate magnetic resonance imaging (MRI) biomarkers of muscle atrophy during cast immobilization of the lower leg, with a focus on 18 patients who underwent 3.0 Tesla (T) MRI five, eight, 15, 29, and 43 days following casting. Measurements of total muscle volume were made on both lower legs, and cross-sectional area (CSA), fractional water content, and T2 were measured in tibialis anterior (TA), gastrocnemius medialis (GM) and lateralis (GL), and soleus (SOL). Fiber pennation angle was quantified in GM. A 17 percent decrease in total muscle volume was observed over the six weeks of immobilization, while the most pronounced loss in CSA was seen in GM (-23.3 (8.7) percent), followed by SOL (-19 (9.8) percent), GL (-17.1 (6.5) percent), and TA (-10.7 (5.9) percent). Substantial declines in CSA also were identifiable in the contra-lateral leg. T2 gained in all muscles: TA 27 (2.5) ms to 29.6 (2.8) ms, GM 34.6 (2.9) ms to 39.8 (5.4) ms, and SOL 34.4 (2.9) ms to 44.9 (5.9) ms. Small decreases were detected in fractional water content, while pennation angle decreased in the cast leg.


Research was conducted to see whether combined open and arthroscopic procedures improve the diagnosis and management of intra-articular lesions and enable surgeons to perform minimally invasive anatomic reconstruction of the lateral ligament complex. Ankle arthroscopy was administered to 40 consecutive patients suffering from recurrent lateral ankle instability who were unresponsive to nonoperative measures. The clinical diagnosis of mechanical instability was verified through imaging and arthroscopic evaluation. All patients underwent arthroscopic Brostrom-Gould repair for management of lateral ankle instability, while secondary lesions were managed as well. The AOFAS score was administered postoperatively to assess functional status, and clinical examination and conventional radiographs were executed in all patients. Thirty-eight patients were reviewed at a mean postoperative follow-up of 9.8 years, and the average AOFAS score was 90 (range, 44-100) at the last follow-up. No significantly different outcomes were observed in patients who had undergone microfractures for management of grade III to IV cartilage lesions compared with patients with no cartilage lesions. Postoperative AOFAS scores were rated as excellent and good in 94.7 percent of patients. Two patients, or 5.3 percent, reported a low AOFAS score; one patient received soft tissue removal for anterior impingement, and one underwent simultaneous medial ankle instability repair.


To test the hypothesis that anatomic variables, such as anterior tibial artery (ATA) variations and the distance between the ATA and joint capsule, may play a role in the occurrence of pseudoaneurysm of the ATA during ankle arthroscopy, researchers analyzed the magnetic resonance images (MRIs) and medical records of 358 ankle cases. Patients were categorized as type 1 (safe type), type 2 (increased risk type), or type 3 (high-risk type) based on locations of the ATA in relation to the peroneus tertius (PT) and the extensor digitorum longus (EDL) tendon on axial MRI, while distances between the anterior joint capsule and the ATA were measured to assess the thickness of the anterior fat pad, which contains the ATA and anterior compartment tendons. The ATA was sited medial to the EDL in 336 cases, or 93.8 percent, rating those cases as type 1. Seven cases or 2 percent were classified as type 2 according to the location of the ATA lateral to the EDL and PT tendon, while 15 cases or 4.2 percent were rated as type 3 because the branching artery was seen lateral to the EDL and PT tendon and the ATA was in the normal position. The average distance between the anterior joint capsule and the ATA was 2.3 mm plus or minus 1.1 mm.

Practice Management

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The conversion to ICD-10 will boost the number of disease and diagnosis codes from 15,000 to over 150,000, and experts warn that organizations unprepared for the conversion could face substantial hikes in accounts receivable, rapid declines in cash flow, high call volumes due to rejected claims, and risk of increased audits and sanctions. A key decision for a healthcare organization is whether the team that deploys ICD-10 should be the same group that is working on electronic health records (EHRs), and two groups detailed different strategies at a recent ICD-10 panel at the College of Healthcare Informatics Executives (CHIME) fall forum. SSM Healthcare of St. Louis is implementing an EHR and many of the same people work on both projects, so the EHR and ICD-10 projects have a steering committee in common.

Meanwhile, Rady Children's Hospital in San Diego established a separate ICD-10 group that also incorporates members of the clinical documentation improvement team. SSM project manager Carole McEwan believes her group will ultimately supply over 100,000 hours of training for ICD-10, and SSM opted to construct its own training system instead of buying an off-the-shelf solution. It will develop six classes to implement throughout its organization. The CHIME panelists advised organizations to be ready for the ICD-10 conversion at least six months ahead of its October 2013 deadline, with McEwan noting that such projects take time to "ramp up."


A new survey from SK&A found that the pace of electronic medical record (EMR) adoption among smaller physician practices is slow on account of three factors—cost of systems, confusion about federal EMR usage incentives, and the practice disruption they might incur. Larger practices are more likely to use EMRs, while experts say that depending on the EMR system, the incentive payments being offered under meaningful use might not be sufficient to cover its cost; SK&A's Jack Schember says doctors are additionally weighing the effect an EMR deployment can have on a practice.

Furthermore, many doctors do not know the rules regarding EMRs and payment incentives, with the SK&A poll finding that many are unaware of the existence of meaningful use incentives. Nearly $700 million was apportioned for establishing 62 regional extension centers (RECs) under the HITECH Act to make small practices aware of the incentive program and help them realize meaningful use, with a goal of reaching 100,000 doctors; many of the RECs only got their funding a few months ago and are just now getting up and running. Many people are unsurprised that early incentive pay recipients are practices already using EMRs because the Centers for Medicare & Medicaid Services wanted to avoid penalizing those who were already employing the technology.

Health Policy and Reimbursement

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The Health Resources and Services Administration (HRSA) has renewed access to the Nation Practitioner Data Bank, a public website of data related to malpractice and disciplinary information of a vast number of doctors in the United States, after an extended period of protests. Despite renewing access to the site, HRSA has restricted the ways in which the data can be used, particularly by journalists. The restrictions include agreeing not to share the data or to use the anonymous information provided on the site to identify a doctor. By restricting the Data Bank's use by journalists, critics argue, HRSA overstepped its authority and is trying to prevent the same type of investigate stories that journalists have written using public court records in the past. The initial removal of the site was caused by the complaints of a neurosurgeon who was angered that a newspaper was able to determine his identity in part through the use of the Data Bank, though the newspaper insists that the knowledge was attained through "shoe leather" reporting from other sources.


A study requested by the Department of Health and Human Services and reported by the Institute of Medicine called for the creation of an independent agency that would be charged with investigating injuries and deaths connected with the use of electronic health records. Though the intention behind the shift from paper records to digitized documents has been to improve care and reduce costs, various difficulties associated with the design and use of current electronic systems pose a threat to patient well-being. The study advocates the consideration of safety measures related to the systems as crucial. It also recommends more culpability from suppliers of the system with regard to software defects and errors.


A study in Health Affairs by researchers from the Rand Corporation and the Harvard School of Public Health questions the feasibility of bundling payments to healthcare providers. The researchers looked at three sites that were trying to implement a bundling methodology developed by the nonprofit Health Care Incentives Improvement Institute. The research showed that efforts moved slowly, with none of the providers or insurers actually making or receiving a bundled payment after two to three years. The initiative faced problems in determining payment rates, as well as combining the bundling methods with insurers' processes for handling claims. The researchers noted, however, that the effort had some good outcomes, including stimulating efforts to coordinate and improve care. The researchers also suggest that future efforts may be more successful due to technical advancements.

Medicine, Drugs and Devices

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Dual energy computed tomography (DECT) scanning appears to aid gout diagnosis by identifying urate crystals that often are symptomatic of the disease, according to Mayo Clinic research presented at the American College of Rheumatology Annual Scientific Meeting. Researchers evaluated the accuracy of the test in diagnosing gout as a complementary or alternative diagnosis method, using two groups of 40 patients. The first group had been diagnosed with gout based on urate crystals being present within their synovial fluid, while the second group had other types of joint disease and a negative joint fluid analysis. DECT scans were administered to all the patients with gout, and a radiologist reviewed the results of each scan, noting whether urate crystals were detected.

A comparison was made between the DECT scan results and the joint fluid analysis results, and then a third group of 30 patients suspected of having gout but whose condition could not be verified by traditional testing was formed. These patients underwent the same CT scanning as the others, and confirmation of urate crystal presence prompted an ultrasound to guide the extraction of synovial fluid with a needle and syringe to verify diagnosis.


A new Illinois statute is enabling use of unclaimed corpses in anatomical education to help fight a shortfall of cadavers, which could signal a national resurgence of the practice of giving medical schools first choice on unclaimed bodies prior to burial. Under the policy, the medical examiner's office keeps an unclaimed body for 14 days while police seek next of kin, but if no family is found and the body weighs less than 300 pounds and does not have any communicable diseases, it is sent to the Anatomical Gift Association of Illinois; the body is embalmed and retained for 60 days before any medical school can use it. If a relative claims the body at any time before or after dissection it will be returned.

Most states still have laws allowing medical schools access to unclaimed bodies for anatomical education, but criticism has discouraged many schools from accepting such cadavers. Laurie Zoloth with Northwestern University Feinberg School of Medicine's Center for Bioethics, Science, and Society believes relatives deserve at least a six-month waiting period before their loved ones are turned over for dissection, and she says officials should make a greater effort to publicize the existence of unclaimed bodies.