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Daniel K. Guy, MD, FAAOS


Published 3/25/2021
Terry Stanton

Digital Orthopaedics Conference Features Chat with AAOS President and Past President

On Jan. 6, the Digital Orthopaedics Conference San Francisco (DOCSF) launched a new platform called DOCSF 365, which is accessible year-round and designed to provide access to curated musculoskeletal content in various formats, including presentations, podcasts, roundtables, and continuing medical education courses from DOCSF and other leading digital health innovators. The DOCSF 2021 two-day event, “The DOCSF Experience,” focused on applications of artificial intelligence and the digital patient experience in orthopaedics, will take place April 23 and 24.

Overall, DOCSF 365 seeks to offer a “high-impact experience focused on the implementation of digital technologies in health care,” said Stefano Bini, MD, FAAOS, founder and chair of DOCSF and a clinical professor in the University of California–San Francisco (UCSF) Department of Orthopaedic Surgery. Presented in partnership with UCSF’s orthopaedics department, “It’s the total preparation needed to be an enterprise change agent,” Dr. Bini said. “DOCSF 365 curates live and on-demand content customized to the needs of the musculoskeletal community. We provide training on the skills necessary to lead change and fresh knowledge and proven ideas from the world’s most trusted companies and thought leaders. We combine innovative formats such as office hours and community portals with master classes, continuing medical education courses, and symposia all presented where, when, and how our audience wants them,” he said.

Daniel K. Guy, MD, FAAOS
Joseph A. Bosco III, MD, FAAOS
Stefano Bini, MD, FAAOS
Thomas P. Vail, MD, FAAOS

DOCSF kicked off in January with an event that included a “fireside chat” featuring AAOS Past President Joseph A. Bosco III, MD, FAAOS; AAOS President Daniel K. Guy, MD, FAAOS; Thomas P. (Tad) Vail, MD, FAAOS, president and chair of the UCSF Department of Orthopaedics; and Dr. Bini, who moderated and participated in the discussion.

Prior to the chat, Dr. Vail spoke of the technological challenges and opportunities in orthopaedics as a “musculoskeletal moonshot.” At the inaugural DOCSF meeting in 2017, Dr. Vail recalled how he and others involved in the initiative were “feeling a certain urgency” over the need to advance orthopaedic innovation. The urgency was “fueled by rising costs, waste, complexity, and burnout when there was truly a digital renaissance going on in the technology community,” he said. “The original exciting idea was of bringing people together, a community of experts from clinical care, technology, and business innovation to create solutions. We talked about putting maximum energy, effort, and investment in the exact part of the Venn diagram where the overlapping circles of compelling need, innovation, and unique application intersect,” he said.

At UCSF specifically, he said, the assembling and empowering of “talented people and technology” yielded a number of actual results: digital programs in online data collection, appointment scheduling, clinical outcome assessment, patient communication portals, secure provider voice and image communication, scheduling, augmented reality in the OR, digitally aided surgical navigation, three-dimensional printing, personalized anatomic models, and digital voice recognition transcription. “We got our feet wet,” Dr. Vail said. “We began to sample what technology could offer, sometimes with sophisticated technology tools and sometimes elementary ones.”

Then, he said, as they were “learning to swim, when we weren’t looking, COVID-19 pushed us into the pool. The pandemic made the status quo irrelevant.” The pandemic, he said, “showed us important truths about the state of digital transformation: (1) We did have some tools that could help us respond quickly; (2) we were not taking advantage of what we were capable of; and (3) there remains tremendous opportunity to amplify, expand, and leverage the same concepts that launched this meeting four years ago. Everything we are doing now we could be doing better. Today it is clear that the delivery of musculoskeletal care needs to happen where patients live, seamlessly in their lives, and the impact of what we are doing must be measured. Together, we have the power to do all of these things. Let’s renew this commitment to digital orthopaedics every day, 365 days a year.”

This article provides highlights from the discussion that ensued.

The opportunity

Dr. Bosco: Dr. Vail is exactly right. We have this great opportunity for our digital transformation. For orthopaedics, we have the means, and we can use it to help our patients and help ourselves give better care. In terms of enhanced communication between physicians and physician-to-patient, the opportunity is there.

Dr. Guy: It’s a great opportunity for us, and we are all still learning. Things are changing so rapidly that what is applicable technology right now gets to be old hat within a year. For instance, we ventured into telemedicine for the very first time. We were forced there because of COVID-19. It has been a useful tool for everyone while we are learning to apply it in the best possible way. This type of care may not be as limited as once believed.

We can be proud of where we are; there is a lot of digital innovation we can point to, but we don’t have to be satisfied. At this stage, despite the advancements we have in digital technology and the great new tools, as Dr. Bosco was saying, we are disconnected from each other—in the information we can share about patients as orthopaedic surgeons. Patients don’t have the access they need. Then all the information about patients that is out there isn’t necessarily accessible at the point of care.

Dr. Bini: It reminds me of the early days of online banking. It was a miserable experience. Today, online banking is the norm because the user experience improved. Our current experience with telemedicine and all the virtual platforms is only going to improve from here. At some point, it will be preferable to the in-person visit. Our ability to interface and be engaged in the design of the platform as orthopaedic surgeons and musculoskeletal practitioners will help create the communication tools that we need.

On the stressors that might have digital solutions

Dr. Bosco: Relating to communication with patients and among physicians: Enhancing interoperability will be a game changer. If I’m a week late paying my credit card bill, everyone in the country knows about it—including all the credit agencies. Yet if I see a patient from San Francisco in my office, I have no access to their medical records. We’ll hear, “Well, there are HIPAA regulations.” Patients are harmed when their medical records are not readily available to all healthcare providers. Easing the HIPAA rules and increasing interoperability of these systems are really going to transform medicine. Each patient ought to have a unique identifier that any doctor can use to access his or her medical records. Anything less than that, I think we are doing our patients and our profession a disservice.

At the Academy, we’ve had discussions with insurers, and they say that the reason they need prior authorization is to make sure that patients are properly indicated for surgery. But those of us who have been around the block a few times know that perhaps payers are using prior authorization to delay care and deny payments for services rendered. Delays in approval and payments are how insurance companies make money. They collect money and pay it out slowly. A solution is the use of a simple digital platform where the payers’ evidence-based surgical criteria are listed. Then we can provide exactly what they need in order to approve surgery. We can provide information and upload imaging studies, rather than mailing or emailing radiographs to someone so they can decide whether a patient needs a laminectomy or knee replacement. To me, that’s expensive for them, and not efficient, but I suspect a little bit of inefficiency is what they want.

Dr. Bini: How is the Academy working on behalf of its members to ensure adequate payment models for these virtual care platforms? It seems like the Academy has done quite a bit of work on our behalf.

Dr. Bosco: The pandemic has accelerated certain trends. I like to tell a story “BC”—before COVID-19. Probably about a year ago, I was in a shared office with one of the younger physicians. He was doing a telemedicine visit, so I said, “I’m going to try it.” And I couldn’t figure it out. Then came COVID-19. Guess what—I had to figure it out, and I was able to do it.

Patients love it—especially new patients. The question is, are we going to get reimbursed for it? The first step was to make sure it was OK to do and we weren’t going to get in trouble for seeing patients across state lines. The second step was to make sure we get reimbursed. We’ve been working diligently with the government and Medicare and Medicaid so that we are going to get reimbursed as we would for an in-person visit. AAOS is advocating strongly, because the patients really like it. Those of us who do it know it’s probably not the most efficient thing for a doctor. It’s much easier to stack patients up in person, but it’s not easier for patients. 

Dr. Guy: When COVID-19 started, the Academy created a resource center on its website that gives pearls for managing telehealth within your office or your system, including how to code. I got feedback that people used it, but as soon as they could start seeing patients in the office again, they reverted to what they were comfortable with.

If you are going to use telemedicine, you are going to have to step up your game and make sure you are doing everything properly and not just checking boxes on a physical exam that you are doing visually. As Dr. Vail said, we were forced into the telemedicine pool. We want to make the best of it so it doesn’t turn us against the technology going forward.

Dr. Vail: An irony is that you do a telemedicine visit and then you go over and type a note about the visit. We have that whole digital interaction with the patient, yet we still have to write a note. It’s illustrative of where we are and what we have to do to make it useful for providers as well as a great experience for the patient. The technology to convert the visit directly into a note is out there; it exists, but we need to get it out broadly.

Dr. Bini: If you had a magic wand, what problem would our colleagues like technology companies to tackle next?

Dr. Bosco: Interoperability is quite important. For instance, the New York state database for narcotics prescription is not hooked up with the Veterans Affairs system, and this has led to overdose—one involving a patient who was on methadone and was given Percocet. People say there are privacy issues, but there are cases where a patient is harmed because of lack of communication.

Technology and digitization can help us with our work-life balance, but right now, they are creating a bit more work. Patients can ping us all the time through electronic systems, such as Epic, but it’s not easy to say when you are going to be working or not. On a weekend, if you get a note through Epic, many feel they have to respond, so there’s a work-life balance issue that has to be ironed out. People need to know if someone is available, and we can use technology to tier what is an emergency and what is not. There is a lot of noise out there, and sometimes important information is caught up in the noise. There is an added liability risk when the “computer” can talk to you and document that it sent critical communications to you and you have no access to read that message.

Dr. Guy: Interoperability is an industry problem. Most big software systems are proprietary. They don’t have an incentive to interact with each other. The technology industry should be solving this problem; they have the means to do it. For us to wait on a legislative solution is kicking the can further down the road.

Dr. Vail: It’s the burden of documentation, and it’s intimately related to interoperability or connectivity that Dr. Guy and Dr. Bosco are talking about. There’s a wealth of tools that can collect all sorts of things. You can put a sensor on a patient; you can get an electrocardiogram on the phone. But how does all that information get put together in a form that’s useable and visible to the next provider looking at the patient’s file or making a decision about surgery? We need to figure out how to use these great tools that collect important information so they connect with one another and then are useful at the point of care. The goal is to decrease the burden of documentation for providers and increase the satisfaction of patients because they have the confidence that the information about them is out there and helping decisions be made that are specific to their situations.

On a favorite technology that can solve a pain point for orthopaedic surgery

Dr. Vail: A patient communication platform. It knows about upcoming surgeries or surgeries they just had. It prompts them and makes them feel well taken care of.

Dr. Bosco: Voice recognition. For those of us who never learned to type—I went to one class in high school and skipped the rest—now even with my hyper-New York cadence, Dragon speech recognition gets everything down. It edits half the things I say.

Dr. Guy: Probably the best things we have are our smartphones. They allow us to communicate securely. My trips to the emergency department (ED) dropped dramatically when I could start sharing radiographs with ED doctors, instead of them describing things to me. I’d have to go in, because maybe the ED doctors didn’t know what they were talking about. Now that I can see the radiographs. It’s made a big difference.

Dr. Bini: Machine learning. I’m a data geek. I love the idea of being able to gather data on 100,000 patients and see the potential of the data to tell us how to treat people and to personalize that information. Let’s use these algorithms to give care for the individual patient.

For information about DOCSF 365 and the agenda for DOCSF 2021 The Experience, visit https://docsf.health/.

Terry Stanton is the senior medical writer for AAOS Now. He can be reached at tstanton@aaos.org.