Health IT vendors and the academic community: The 2014 ACMI debate.

The American College of Medical Informatics (ACMI) periodically hosts a debate at the American Medical Informatics Association (AMIA) fall symposium on a timely topic in biomedical informatics. In 2014 a panel of ACMI fellows debated the following proposition: "The lack of interaction and collaboration between health IT vendors and academic clinical informatics units is stifling innovation and will continue to have a detrimental effect on the evolution of commercial products." Debaters disagreed on the level of interaction and collaboration between the health IT sector and academia and disagreed on whether and by whom innovation was actually taking place. While collaboration between industry and academia was seen as desirable by all of the debaters, there was an acknowledgment that these groups have notably different roles and responsibilities. There was consensus that a path forward should be found, and that AMIA itself has an important role to play in effecting this.

Comparison of Intraoperative C-Arm Fluoroscopy to Postoperative Radiographs in Operative Fracture Fixation.

The purpose of this study is to evaluate the differences between intraoperative C-arm images and postoperative plain film radiographs and the utility of each in assessing fracture fixation and determining postoperative management. Intraoperative and postoperative images with varying fracture types and locations were analyzed. C-arm images were compared to postoperative plain film radiographs for each treated fracture and reviewed by two orthopaedic surgeons. Image adequacy and quality for each radiograph were analyzed. The quality of reduction and fixation was also analyzed. Information was apparent on the postoperative radiographs, such that a reviewer felt that the postoperative treatment plan should change in 8.2% of cases. In the cases where treatment change was recommended, fracture gap, rotation, and angulation were found to be the strongest predictors. The ability of intraoperative and postoperative images to reflect fracture gap, rotation, and angulation may vary between images.

Analyzing financial performance in the new world.

Over the past several years, health care has seen the beginnings of a significant transformation in the nature of analytics. This transformation is being driven by the advent of a new world in which providers hold increased accountability for the efficiency, quality, and safety of the care that their organizations provide--and it is occurring across several dimensions.

Applications of SPECT/CT in the Evaluation of Spinal Pathology: A Review.

BACKGROUND: Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS: A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS: SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS: SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE: SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology.

The role of healthcare IT: becoming a learning organization.

IT advances that will support healthcare providers' transition toward becoming "learning organizations" include the following: The increase in big data" (patient data captured in EHRs, coupled with data from imaging, molecular medicine, patient-provided data, and insurance claims). Real-time analytics and novel decision aids. Ease-of-use advancements and effective data capture methods. Efforts to increase facile interoperability. Extended reach of EHRs in gathering data from other processes and sources

Instrumenting the health care enterprise for discovery research in the genomic era.

Tens of thousands of subjects may be required to obtain reliable evidence relating disease characteristics to the weak effects typically reported from common genetic variants. The costs of assembling, phenotyping, and studying these large populations are substantial, recently estimated at three billion dollars for 500,000 individuals. They are also decade-long efforts. We hypothesized that automation and analytic tools can repurpose the informational byproducts of routine clinical care, bringing sample acquisition and phenotyping to the same high-throughput pace and commodity price-point as is currently true of genome-wide genotyping. Described here is a demonstration of the capability to acquire samples and data from densely phenotyped and genotyped individuals in the tens of thousands for common diseases (e.g., in a 1-yr period: N = 15,798 for rheumatoid arthritis; N = 42,238 for asthma; N = 34,535 for major depressive disorder) in one academic health center at an order of magnitude lower cost. Even for rare diseases caused by rare, highly penetrant mutations such as Huntington disease (N = 102) and autism (N = 756), these capabilities are also of interest.

Using technology to reveal true costs.

Healthcare leaders should address three important questions as they prepare to implement new costing systems: Do all providers in their organizations' systems, networks, or partnerships share the same definitions of unit of care and of fixed, variable, incremental, direct, and indirect costs? What are the maintenance processes and protocols for cost center and period matching of revenues and costs? If some providers within a network or partnership are not using costing systems, can an enterprise derive surrogate cost per unit of care?

Factors governing the adoption of artificial intelligence in healthcare providers.

Artificial intelligence applications are prevalent in the research lab and in startups, but relatively few have found their way into healthcare provider organizations. Adoption of AI innovations in consumer and business domains is typically much faster. While such delays are frustrating to those who believe in the potential of AI to transform healthcare, they are largely inherent in the structure and function of provider organizations. This article reviews the factors that govern adoption and explains why adoption has taken place at a slow pace. Research sources for the article include interviews with provider executives, healthcare IT professors and consultants, and AI vendor executives. The article considers differential speed of adoption in clinical vs. administrative applications, regulatory approval issues, reimbursement and return on investments in healthcare AI, data sources and integration with electronic health record systems, the need for clinical education, issues involving fit with clinical workflows, and ethical considerations. It concludes with a discussion of how provider organizations can successfully plan for organizational deployment.

The Feasibility of Translaminar Screws in the Subaxial Cervical Spine: Computed Tomography and Cadaveric Validation.

BACKGROUND: The use of translaminar screws may serve as a viable salvage method for complicated cases. To our understanding, the study of the feasibility of translaminar screw insertion in the actual entire subaxial cervical spine has not been carried out yet. The purpose of this study was to report the feasibility of translaminar screw insertion in the entire subaxial cervical spine. METHODS: Eighteen cadaveric spines were harvested from C3 to C7 and 1-mm computed tomography (CT) scans and three-dimensional reconstructions were created to exclude any bony anomaly. Thirty anatomically intact segments were collected (C3, 2; C4, 3; C5, 3; C6, 8; and C7, 14), and randomly arranged. Twenty-one segments were physically separated at each vertebral level (group S), while 9 segments were not separated from the vertebral column and left in situ (group N-S). CT measurement of lamina thickness was done for both group S and group N-S, and manual measurement of various length and angle was done for group S only. Using the trajectory proposed by the previous studies, translaminar screws were placed at each level. Screw diameter was the same or 0.5 mm larger than the proposed diameter based on CT measurement. Post-insertion CT was performed. Cortical breakage was checked either visually or by CT. RESULTS: When 1° and 2° screws of the same size were used, medial cortex breakage was found 13% and 33% of the time, respectively. C7 was relatively safer than the other levels. With larger-sized screws, medial cortex breakage was found in 47% and 46% of 1° and 2° screws, respectively. There were no facet injuries due to the screws in group N-S. CONCLUSIONS: Translaminar screw insertion in the subaxial cervical spine is feasible only when the lamina is thick enough to avoid any breakage that could lead to further complications. The authors do not recommend inserting translaminar screws in the subaxial cervical spine except in some salvage cases in the presence of a thick lamina.

Sacroiliac Joint Fusion-A Shift Toward Variant Anatomy and Clinical Implications.

OBJECTIVE: To investigate impact of patient factors and sacroiliac joint (SIJ) anatomical structure on SIJ fusion outcomes. METHODS: This single-center, retrospective, observational study evaluated patients diagnosed with SIJ dysfunction refractory to conservative measures who had available preoperative imaging of the sacrum and underwent SIJ fusion surgery. The impact of patient sociodemographics on pain improvement was assessed by Mann-Whitney U test. Differences in patient sociodemographics and outcome information between anatomical subtypes were assessed with χ2 and Kruskal-Wallis tests. χ2 test was used to compare joint anatomy distribution between studies analyzing SIJ variations. RESULTS: We included 77 total joints that underwent instrumentation. There were significant differences between the anatomical subtypes with female sex having significantly higher rates of non-normal joint anatomy. Younger age was significantly more common in bipartite/dysmorphic anatomy (53.9 years) than normal anatomy (70 years) (P < 0.05). There was a trend toward better outcomes in bipartite/dysmorphic and accessory variants, while semicircular defect and crescent variants trended toward worse outcomes. Nonnormal anatomy was significantly more frequent in our population than previous reports on nonpathological SIJ. CONCLUSIONS: A pathological SIJ has a significantly higher prevalence of variant joint anatomy. There appears to be a trend toward differences in surgical outcomes based on SIJ anatomy. Future research with larger sample sizes is necessary to confirm these differences.

Strengthening revenue cycle capabilities in an era of reform.

Strategies that healthcare finance professionals should incorporate to help their organizations respond effectively to payment reforms include: Assessing the organization's ability to capture and share relevant data. Educating themselves, the board of trustees, and the medical staff on pertinent rules as payment reforms are rolled out. Examining inefficiencies related to care processes. Establishing policies and procedures to address "commingled" data.

Cloud computing can simplify HIT infrastructure management.

Software as a Service (SaaS), built on cloud computing technology, is emerging as the forerunner in IT infrastructure because it helps healthcare providers reduce capital investments. Cloud computing leads to predictable, monthly, fixed operating expenses for hospital IT staff. Outsourced cloud computing facilities are state-of-the-art data centers boasting some of the most sophisticated networking equipment on the market. The SaaS model helps hospitals safeguard against technology obsolescence, minimizes maintenance requirements, and simplifies management.

Interoperability: the key to breaking down information silos in health care.

In health care, interoperability--the ability of healthcare information systems to work together and share information within and across organizational boundaries--involves: Data exchange, Infrastructure interoperability, User interface interoperability, Process interoperability.

Leveraging healthcare IT to improve operational performance.

The use of technology to automate clinical workflows at The Chester County Hospital in West Chester, Pa., has resulted in the following benefits: An 82 percent reduction in hospital-acquired MRSA infections. A significant reduction in catheter-associated urinary tract infections. Enhanced documentation of pre-existing pressure ulcers (The Centers for Medicare & Medicaid Services classifies pressure ulcers that develop during a hospital stay as "never events").

Management of degenerative spondylolisthesis: development of appropriate use criteria.

BACKGROUND CONTEXT: Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE: The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process was used. METHODS: The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS: There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Healthcare IT trends raise bar for information security.

A provider's initial priorities for protecting the security of healthcare IT should include the following: Security governance and management. Laptop and device encryption. Internal content filtering. E-mail encryption. Access management. Social media policies and guidelines.

The strategic importance of data.

Two factors--accountability for care and an increased adoption of interoperable electronic health records (EHRs)--will significantly increase the importance of data for healthcare organizations. These factors have significant data ramifications in four areas: payment reform, data use policies, IT strategy, and data management. As data become a strategic asset, healthcare finance executives will need to become significant contributors to their organizations' EHR initiatives and data management strategies.

Coccygectomy for the treatment of therapy-resistant coccygodynia.

Coccygodynia (pain in the region of the coccyx) has many causes, but it may be posttraumatic beginning after a fracture or contusion. Pain is typically triggered by or occurs while sitting. Nonsurgical management, including cushions, nonsteroidal anti-inflammatory drugs, and corticosteroid injections, can be successful in up to 85% of patients. The objective of the study was to show that coccygectomy can be a successful surgical treatment for patients who fail nonoperative treatment. This study is a retrospective analysis of all patients who underwent a coccygectomy performed by one surgeon between the years 2002 and 2008. All patients were asked to complete an Oswestry low back pain disability questionnaire and a visual analog pain scale. The average Oswestry disability score was 25.75%. The average visual analog score was 3.4 cm. Four patients sustained a wound breakdown. The study concluded that for patients with conservative therapy-resistant coccygodynia, operative treatment with coccygectomy is a feasible management option.

Community relations 2.0.

Before the Internet, organizations had far more time to monitor and respond to community activity, but that luxury is long gone, leaving them in dire need of a coherent outreach strategy, fresh skills, and adaptive tactics. Drawing on the authors' study of more than two dozen firms, this article describes the changes wrought by social media in particular and shows managers how to take advantage of them--lessons that Kaiser Permanente, Domino's, and others learned the hard way. Social media platforms enhance the power of communities by promoting deep relationships, facilitating rapid organization, improving the creation and synthesis of knowledge, and enabling robust filtering of information. The authors cite many examples from the health care industry, where social media participation is vigorous and influential. For instance, members of Sermo, an online network exclusively for doctors, used the site to call attention to and organize against insurers' proposed reimbursement cuts. And on PatientsLikeMe, where people share details about their chronic diseases and the treatments they've pursued, charts and progress curves help members visualize their own complex histories and allow comparisons and feedback among peers. As you modernize your company's approach to community outreach, you'll need to assemble a social media team equipped to identify new opportunities for engagement and prevent brand damage. In the most successful firms the authors studied, community management was a dedicated function, combining marketing, public relations, and information technology skills.