On (and Off) the Record

Dear OTW Reader: $44K CMS Bounty and How to Get It…Bundling to Increase Income? …Most Commonly Injured Joint Diagnosis Being Standardized…the “Bible” of Orthopedic Oncology Surgery Released…Previous NIH Grant Winner Does it Again!…and more.

$44, 000 CMS Bounty for EHR: What You Need to Know

For ten years, Herb Alexander, M.D., a retired Captain in the U.S. Navy, has been asked by AAOS (American Academy of Orthopaedic Surgeons) to give lectures on the importance of electronic health records (EHR). Dr. Alexander, who is president of the Society of Medical Consultants to the Armed Forces, tells OTW, “Regardless of how we feel about it, paper is on the way out of medical offices. Efficiency aside, the major incentive for converting to EHR is the fact that Medicare will begin penalizing us if we don’t use it. I’ve had time to get used to it…and I love it. My interest in EHR goes back to when I was in the Navy. There were different computer systems for different functions…one for appointments, another for lab tests, one to register for X-ray and none of them ‘talked to’ each other. I swore that if I ever got into practice I’d have one system that handled everything. In 2002 I did just that…and ended up being an early adopter of the electronic office, something that has increased my efficiency by leaps and bounds.

“How to do this? Begin by contacting different vendors and doing an RFP. There are programs with lots of bells and whistles, but if it’s not what you need then it’s not helpful. Something important to recognize is that if a vendor is not focused on educating you about their program then they are probably selling you a bill of goods. Any legitimate vendor should be willing to send you a demo so you can try their system. Equally as critical is to ensure that this vendor will stand by you for ‘meaningful use.’ CMS [Centers for Medicare and Medicaid Services] will pay doctors up to $44, 000 if they convert to EHR, but to get that money the software has to be certified for ‘meaningful use.’ Ease of use is also important…you don’t want it to slow you down such that it takes time away from patients. The most efficient systems use voice recognition and templating. And my experience has been that patients feel more comfortable knowing that all of their information is in an EHR. They are impressed when they can leave my office with a paper copy of everything I just did.”

First in Ten Years: Oncology “Bible”

James C. Wittig, M.D., along with Martin Malawar, M.D. and Jacob Bickels, M.D., have co-authored “Operative Techniques in Orthopedic Surgical Oncology, ” the first book of its kind in ten years. Dr. Wittig, Chief of Orthopedic Oncology at Mount Sinai Medical Center in New York, tells OTW, “My co-authors and I have tremendous experience in treating these types of patients. We have also developed surgical techniques that have been proven to be reliable and safe methods of dealing with different types of tumors. With this book, residents, fellows and practicing orthopedists have step-by-step instructions to treating any and all type of tumor. Also making this book special are the hundreds of color illustrations demonstrating what amounts to 10 to 20 years of surgical techniques…not to mention the videos that correlate with the specific procedures.

“Most orthopedists don’t see many tumors, and are understandably less informed about how to handle certain situations. This book shows you how to ‘stay out of trouble, ’ especially with biopsies—something that is so important that done wrong, can result in unnecessary amputation. Each step for each kind of tumor in each anatomic location…that is what we have laid out.”

Most Commonly Injured Joint Diagnosis Being Standardized – Finally! 

John Kennedy, M.D., is an assistant attending orthopedic surgeon at Hospital for Special Surgery (HSS). He recently co chaired the International Congress on Cartilage Repair of the Ankle in Dublin, Ireland, with Drs. Rick Ferkel and Niek van Dijk. Dr. Kennedy tells OTW, “We brought together a panel of 25 surgeons and scientists as well as over 200 attendees from the U.S., Europe, Asia and Australia to establish a foundation for international collaboration and innovation regarding ankle cartilage care. One of the topics we tackled was whether to repair or replace cartilage defects…the debate was, ‘Should we consider microfracture repair in lesions below 1.5cm or reduce that size knowing that when we repair there will be degradation of the repaired fibrocartilage after ten years?’ We haven’t answered that question conclusively yet but we do know that we should not ignore these lesions regardless of size. The fact is that every time we treat an ankle fracture we are potentially walking away from the table with the job half done. Why? Because we know that the cartilage has been damaged—and that may be a good reason to at least look inside the joint when you are fixing the fracture.

“Perhaps the most important thing we did was tackle this longstanding controversy: how to standardize the diagnosis of an osteochondral lesion of the talus (OCL). We have the luxury of an MRI here in the U.S., whereas in the rest of the world this technology is not always readily available. In areas where CT scan is used as a diagnostic tool it measures the bony defect but not the cartilage defect either at the initial diagnosis or at follow up. Ideally a combination of MRI and CT scan would give us the best imaging of this challenging lesion. At some point MRI with T2 mapping will become more universally available. This will really give us the information we are looking for as it can tell us the quality of the reparative tissue as well as the quantity of the tissue repair.

“Over the next six months or so the participants will attempt to standardize the issues of diagnosis, treatment and follow up of talar OCLs. The AO Foundation did this for fracture fixation four decades ago and it has made a huge difference for patients and surgeons. The exciting thing is the progress we’ve made so far in this field in a short period of time. Ten years ago this event could not have happened as there was little interest in ankle cartilage. Amazing, really…given that the ankle is the most commonly injured joint in an athlete. It’s now considered to be ‘sexy’ and that’s good for all of us.”

Bundling to Increase Reimbursement?

A Horizon Blue Cross Blue Shield program in New Jersey just might be a snapshot of what’s coming your way. Richard Popiel, M.D., M.B.A., president and chief operating officer of Horizon Healthcare Innovations tells OTW, “We launched our Joint Replacement Episode of Care Program in January 2011, and we now have more than 30 joint replacement surgeons participating in this initiative. By paying one sum for episodes of care we are helping to not only meet the national agenda to reduce healthcare costs, but the effort to improve quality as well.

“Surgeons are surgeons because they like to be in the OR…we asked these practices to think differently. We asked them to think about costs as related to the period prior to surgery, the period after surgery, the post discharge period (up to 90 days), as well as the time the patient is in the hospital. Did the patient get the appropriate prophylaxis for DVT [deep vein thrombosis]? Cost…the major cost is the inpatient experience and the key driver there is cost of the implant. Discharge—we had to understand where someone was being discharged to and the relative advantages of skilled nursing/rehab/homecare. To ferret through all this we used a technology called Prometheus, which groups all the pieces of an episode.

“In our preliminary results we are seeing 100% compliance with prophylaxis, and every case is getting the appropriate preop antibiotics…great quality outcomes. As for reimbursement, this has the potential to increase compensation for doctors and/or hospitals because in some cases hospitals and doctors are partnering. We want to provide rewards for eliminating things that add no value like extra days in a post acute facility. But a fundamental point here is that there are safeguards to ensure that we don’t create any perverse incentives to cut corners. A physician cannot access additional compensation unless he or she triggers certain quality parameters.”

Melissa Kacena, Ph.D. Awarded Second NIH R01 Grant

Melissa Kacena, Ph.D. is Assistant Professor of Orthopaedic Surgery Indiana University School of Medicine…and she is now the recipient of two NIH R01 [National Institutes of Health] grants. This latest grant will fund research on how the protein thrombopoietin can enhance bone healing in mice. Dr. Kacena was only awarded her first R01 this past fall–Regulation of Osteoblast Function by Megakaryocytes: Key Signaling Proteins. Dr. Kacena received her Ph.D. in Aerospace Engineering from the University of Colorado, Boulder in collaboration with Harvard Medical School and NASA Ames Research Center in 1999. She then began her postdoctoral training in the Department of Orthopaedics and Rehabilitation at Yale University School of Medicine. In 2002, she was promoted to research faculty at Yale and was subsequently promoted to Assistant Professor in 2005. Dr. Kacena was recruited to IU in 2007.

Her past honors include the American Society for Bone and Mineral Research Young Investigator Award, the Advances in Mineral Metabolism/American Society for Bone and Mineral Research Young Investigator Award, the National Society for Histotechnology Diamond Cover Award, the Sun Valley Workshop on Skeletal Tissue Biology, Alice L. Jee Memorial Young Investigator Award, and the US Bone and Joint Decade Young Investigators Initiative.