Veronica Diaz, MD, is the medical director of orthopedics at Boca Raton, Fla.-based healthcare software company Modernizing Medicine. Here, she shares her thoughts on outpatient orthopedics, private equity and the ASC industry.
Note: Responses have been lightly edited for style and clarity
Question: What changes or opportunities are you expecting to see for outpatient total joints in the coming years?
Dr. Veronica Diaz: There is strong consensus among orthopedic surgeons, payers, administrators and healthcare industry forecasters that there will continue to be a shift toward total joint replacement performed in an outpatient or ambulatory setting. Three of the driving forces behind this trend are safety, cost and patient preference.
Safety. Advances in regional anesthesia allow for patients to be discharged home comfortably on the same day as total joint replacement, whereas in the past, concern over pain control was a major factor in admitting the patient to the hospital overnight. Regional anesthesia also minimizes the requirements for general anesthesia, which can result in nausea or grogginess that precludes the patient from going home safely on the same day as surgery. The widespread use of tranexamic acid, an inexpensive and readily available medication to minimize blood loss, allows for same-day discharge with reduced concern for problematic acute postoperative anemia. Increasingly precise surgical techniques and evolution of implant and instrument design, including the advent of GPS software for implant positioning, have also propelled the shift toward total joint replacement in the outpatient setting.
Cost. With increasingly limited healthcare resources and an aging population, there is a tremendous emphasis being placed on cost containment, and the ambulatory setting provides an ideal opportunity for cost reduction in the realm of total joint replacement. ACO participants and others who receive bundled payments for services such as total joint replacement are further incentivized to reduce costs associated with total joint replacement. Eliminating an overnight stay affords an opportunity to drastically reduce the overall cost of a joint replacement-related episode of care.
Patient preference. An increasing number of patients are choosing to have their hip, knee or shoulder replaced in an outpatient setting. Many patients are averse to the idea of an overnight stay in the hospital when they are not sick. They prefer the comfort of their own surroundings as they recover.
Q: Are there any kind of overarching trends that you're seeing right now in outpatient orthopedics?
VD: Despite reimbursement in general not keeping up with inflation relative to other specialties, orthopedic procedures still reimburse fairly well, resulting in major healthcare and hospital systems aggressively competing for patients and for surgeon talent. Physician-owned orthopedic practices remain dominant players, and that is not expected to change, as many orthopedic surgeons value their autonomy and independence over the reduced operational burden of an employment position.
There is a trend in outpatient orthopedics towards harnessing the power of technology to reduce documentation burden, save time and better support orthopedic surgeons in caring for their patients. However, adoption of EHRs has arguably been more challenging for orthopedic surgeons than other specialties, owing to the unique requirements of documenting an orthopedic visit as opposed to specialties with a narrower focus. Not only do orthopedic surgeons see patients from all walks of life (adults, children, professional athletes, the senior population), but they also deal with vastly different anatomic regions (hand, spine, knee) and various systems (integumentary, neurovascular, musculoskeletal) within those regions.
The nuances inherent in orthopedic documentation are further underscored when trying to capture the essential elements of an orthopedic encounter with a nonorthopedic-specific EHR. Many EHR platforms are designed with the primary care practice in mind and may be lacking in functionality that is fundamental to an orthopedic practice. This in turn leads to disrupted workflow, physician burnout and missed opportunities for reimbursement. Orthopedic practices should partner with EHR platforms that employ orthopedic-specific software designed for orthopedic surgeons by orthopedic surgeons.
Q: How do you hope the ASC industry will change in the coming years?
VD: I am excited to see ASCs join the digital age. It is unfortunate that in 2020, the majority of communication in the healthcare industry is still paper and fax-based. Because of the need to coordinate with numerous physician practices running the gamut of specialties, ASCs will benefit immensely from interoperable, streamlined technology that is simply not possible via paper and fax communication. Furthermore, paper records pose a challenge to ensuring that documentation meets reimbursement and regulatory requirements. It is prohibitive toward capturing the necessary data to identify processes that need optimization to improve patient safety or efficiency within the ASC setting.
An investment in adequate technology will also help ASCs address the challenges of maintaining inventory and streamlining patient paperwork. ASCs should be looking to adopt inventory management systems that are easily customizable to individual workflows and can adapt to unique schedules.
Q: Is there any new technology you're looking forward to on the horizon?
VD: I am bullish about the role telemedicine will play in the near future, and I believe certain elements of orthopedic care are ideally suited for it. What if you want to follow up on a patient’s response to an injection? Or the patient is unable to leave work in time to make it to your office for an appointment to review an MRI? Or if you just want to perform a quick range of motion check? None of these scenarios necessarily requires an in-person visit. Enter telemedicine.
We now also have unprecedented opportunities to gain insight into patient recovery through wearable devices and apps that encourage patients to comply with activity restrictions, physical therapy and follow-up appointments. Companies like WebPT and various other clinical SaaS (software as a service) innovators are collaborating directly with EHRs in order to allow effortless collaboration among team members caring for patients.
This technology will be particularly important in rural populations with limited access to specialty care. It also fits nicely into the increased emphasis on in-home care for the elderly population facing problems with mobility, transportation and social support. Patient privacy and security issues must be given the utmost consideration in the design and implementation of these promising technologies.
Q: Do you have any tips or things to know before starting a total joint program?
VD: Recruit personnel to your center with leadership experience from a high-volume total joint center.
Initiate a policy for infection control specific to arthroplasty surgery. Ensure the entire team is on board, and foster a culture of respect for minimizing operating room traffic and other measures that optimize sterility and reduce risk of surgical site infection.
Ramp up slowly and methodically. Start with your most proficient surgeons and healthy, low-risk patients.
Develop thoughtful, standardized processes that minimize system errors. Engage all departments (pre-admission testing and scheduling, pre-op, OR teams, PACU, follow-up teams).
Develop detailed protocols for how adverse events will be handled (cardiac arrest, acute blood loss, periprosthetic fracture, missing equipment).
Do several dry runs and dress rehearsals simulating various adverse scenarios.
Track your outcomes through validated instruments and make adjustments or reverse course on areas that present patient safety issues.
Q: Do you think private equity will have an impact on the orthopedic specialty? Why or why not?
VD: Recent years have seen a huge increase in private equity firms backing orthopedic practices and ASCs. Some industry experts have surmised that this is driven by two factor — the increase in total joint replacements taking place in outpatient settings, as well as the increase in the volume of these surgeries. From a private equity perspective, the revenue opportunities can be a driver of this interest.
From the perspective of private practice, having additional resources to help with the changing regulatory landscape and helping alleviate the administrative side of running a business is seen by some as a positive. However, there is speculation that the rise in private equity investment and influx in consolidation could impact personalized patient care and autonomy among physicians.