MRI From Your Smartphone? Auto Billing When You Step Out of the Exam Room? Yes! // New HSS Study to Tackle Critical ACL, UCL Failure Issue // and More!

The 45 Second Exam Note

Want an ortho-specific app that lets you peel back the skin and zoom in on joints? Wishing you could order an MRI from your smartphone? The time has come…and the app was developed by practicing orthopedic surgeons. Matthew Stiebel, M.D. is an orthopedic surgeon with Jupiter Medical Center in Jupiter, Florida. Dr. Stiebel, a sports medicine specialist who has been an instructor for the AANA (Arthroscopy Association of North America) and AOSSM (the American Orthopaedic Society for Sports Medicine), tells OTW, “I have used several electronic medical record (EMR) systems, all of which came up short. When approached by Dan Cane (co-founder of Modernizing Medicine and past co-founder of Blackboard) to help develop a radically different EMR system for orthopedic surgeons, I listened, and then I got involved.”

“EMA Orthopedics is a native iPad app with an easy interface that maximizes screen space. Surgeons who are 60 and older are very comfortable navigating the programs. In orthopedic surgery practices there is no time to be leisurely between patients, so we need something that stays on the move with us. As for speed, it takes me approximately four minutes to dictate a note; with this app I tap right through the form in 45 seconds! And EMA Orthopedics, which is cloud based, makes it easy for surgeons to remain connected to the Internet as they move easily between exam rooms.”

“So you carry the iPad all day, and as you walk out of an exam room you can fill out the physical, and then the program automatically bills for me and sends the necessary forms to the billing department. No other EMR does this. I can take a picture of, for example, a swollen knee, and add it to the chart. Sometimes I even draw on the pictures when I’m telling a patient where the ACL graft will go—then that goes in the chart as proof that I have explained things to the patient. I even bring it into the OR because I can read all the notes, take pictures of the radiographs, and make them part of the chart.”

“One thing that truly differentiates this program is the way it holds data. We put data in that is structured. It is not like data you have from dictation where if you want to do research, then you must pull out all the cases with, for example, broken arms, and subdivide them into type X. That is very difficult to do when the data isn’t structured. With this program you can perform searches based on the type of fractures, on all ICD-9 or ICD-10 codes. You can also see what all other users of EMA Orthopedics have done using de-identified data. If we can take advantage of this opportunity to perform such a large meta analysis of data then we will have a great chance to see what is working and what is not.”

“We are partnering with IBM Watson to create something known as schEMA, which will be powered by Watson and will expand the power of what we are doing now. This will allow users to interact with the system in a way that’s cognitive…like Siri on the iPhone. With schEMA, users can pose queries, describe symptoms or search for information and statistics about various conditions and matches those queries with clinically useful content. schEMA will use medical journals and other to parse the current evidence and present relevant answers. We have started developing schEMA for dermatology and plan to further develop into other specialties.”

New HSS Study Tackling Critical ACL, UCL Failure Issue

“Failure, ” says a savvy surgeon, “is the dirty underwear drawer of orthopedic surgeons.” David Altchek, M.D. is an attending orthopedic surgeon and co-chief in the Sports Medicine and Shoulder Service at Hospital for Special Surgery (HSS). He is also the Medical Director for the New York Mets. Dr. Altchek tells OTW, “In both the anterior cruciate ligament (ACL) of the knee and the ulnar collateral ligament (UCL) of the elbow we now have solid techniques and we are getting good outcomes. So now, we are getting greedy—appropriately so—and we want ‘no’ failures. We are doing MRIs postop to look at reconstructing ligaments in both the UCL of the elbow and the ACL of the knee. We need to determine when the ligament starts to mature and when we can start loading it. Perhaps some people are returning to pivoting and throwing before they are ready.”

“In this study, which involves five HSS surgeons, we are aiming for 200 ACLs and 100 UCLs. We hypothesize that some people heal slower and therefore the ligament doesn’t mature as fast. By taking MRIs a month postop, then at three months, seven months, and one year, we will have a solid idea of what these ligaments look like in periods of healing. We will be able to pinpoint the junctures at which they change and mature.”

“Our study population is young athletes between skeletal maturity (approximately 15 to 25 years of age). They must have had no prior surgeries and no significant associated injuries. In the ACLs we are studying the hamstring and patellar tendon; we will compare them to each other and to each group. Then we will study two groups of grafts in the UCL, comparing them to each other and to their own group. We will use the same graft in all subjects.”

“Return to play is confusing and we need more accurate information. Failures are the dirty underwear drawer of orthopedic surgeons; they don’t talk about them much. We need to turn that around.”

First-Ever Step by Step Measurement of Operative Time in Scoliosis

Apparently, when it comes to idiopathic scoliosis, there is room for improvement in making the operation more efficient which has important implications for the patient. Baron Lonner, M.D. is the chief of the Division of Spine Surgery in the Department of Orthopedic Surgery at  Mount Sinai Beth Israel and director of the hospital’s Spine Institute of New York. He and his colleagues at Rady Children’s Hospital in San Diego and at Nemours Children’s Hospital in Delaware set out to get the details. Dr. Lonner tells OTW, “We divided adolescent idiopathic scoliosis surgery into 14 clear steps and measured the time associated with each step. We also measured blood loss because prolonged operative times lead to more blood loss, more potential for infection, and more anesthesia.”

“You also want to minimize time in the OR because of increased costs that then take away from other services the hospital can provide for patients. We found that there are four main components in terms of operative time. The first is exposing the spine to put an implant in and the second is putting the screws in—each step takes 15-20% of the overall operative time. The third component is putting the rods in and performing manipulations for correction of the spinal deformity. The fourth component is closure of the soft tissue compartments."

“We are now working on the use of power tools in the OR because we have found that they increase accuracy. But I am also seeing a significant decrease in operative time because I and some other surgeons are using these tools (approximately 30-50% faster). We are also going to be looking at ways to improve the efficiency of closing the spine. One option is sutures that you can run continuously; another possibility is to use skin glue and a special mesh that holds the skin edges together.”

“One way to decrease postoperative pain and blood loss is to not expose the spine as far out to each side. To do that, however, we must develop new tools for insertion of the screws and new soft tissue guides. There are techniques where the muscle and skin are not fully exposed but that has not taken hold for idiopathic scoliosis because our results are so good with standard “open” approaches. We might need to consider some hybrid of traditional open and MIS (minimally invasive surgery)…something that will involve less dissection of the musculature, less bleeding, and less pain, but with reliable deformity correction, good fusion, and healing. We are also working on improving the implants themselves so as to facilitate correction maneuvers and decrease the amount of dissection required to get to the spine.”

“Interestingly, we found some variation amongst surgeons as far as the order of the steps performed and in the time it takes to do the steps. So here we have an opportunity to standardize the procedure such that those surgeons who perform fewer of these surgeries can be successful in improving outcomes for their patients. The bottom line is that more experience in performing these 14 steps also impacts how accurately and efficiently surgery is performed.”