The meeting, co-sponsored by the HWB Foundation and the AAOS Outcomes Special Interest Group, started at 11:30 a.m. HWB Board Members in Attendance: Bradford Henley, M.D., David Karges, D.O., Henry Mankin, M.D., Augusto Sarmiento, M.D., Marc Swiontkowski, M.D., Edward Yang, M.D.

As part of an AAOS Orthopaedic Knowledge Online Symposium on Evidence Based Practice, (http://www5.aaos.org/oko/page1.cfm?topic=EBP001), an article has been published detailing the experience of the HWB Foundation with orthopaedic trauma data collection over the past 15 years (http://www.hwbf.org/oko/) using a direct physician structured data entry instrument called the "Trauma Register" (TR). http://www.hwbf.org/ota/trdemo/

There are many challenges that occur with registries, but "input fatigue failure" continues to be the major stumbling block for direct physician data entry. However, the TR continues to maintain a 25% survival rate (http://www.hwbf.org/hwb/am2007/data2.htm) which compares favorably to the 10% electronic medical record adoption rate reported by the American Medical Informatics Association.

The HWB web site educational resources and activity continue to grow (http://www.hwbf.org/hwb/am2007/webstat.htm). There were some 5 million hits in ’06 but some 37% are by robots – automated search engine programs. The most heavily trafficked site is the OTA Basic Fracture Course.

The HWB Foundation presented its income and expenditures for ’06 (http://www.hwbf.org/hwb/am2007/fin1.htm) and the budget for ’07 (http://www.hwbf.org/hwb/am2007/fin2.htm) which was approved by majority vote of a quorum of HWB Board Members.

The MGH Treadwell Library has been in existence for 160 years. Today it has 9 professional librarians, 12 assistants and a web master. Recognized as a leader in the archive and retrieval of biomedical print matter, it entered the electronic information age in the 1970’s having been selected by the National Library of Medicine as a Medline Search Center. It started with teletype technology and then in the 1980’s developed a number of innovative interfaces and the first on-line card catalog. It was a medical informatics pioneer in the provision of web information resources. Mrs. Mankin provided a demonstration of the current web site

http://www.massgeneral.org/library/default.asp

which is quickly and easily navigated with the "quick picks" menu found in the left frame of the web page.

While much of the library content is available on-line from extramural locations, e.g. office and home computer workstations, the library remains a integral part of the hospital information delivery system. There are over 2,000 visitors to the library each month, printing as many as 30,000 pages!! The computer screen remains suboptimal for reading, so while computer users may be able to read short articles on their screens and they usually prefer to print out the longer articles to read on paper. In polling library visitors, they come for a quiet study area but also the collegiality of those visiting is an important motivating component to make a physical – as opposed to virtual - visit.

The library expects that a number of things to occur over the next few years, such as;

• All biomedical journals will be electronic

• There are over 11,000 medical journals and the number will continue to expand.

• Certain journals such as the JBJS are and will be offering access to back issues greater than 5years old for free

• Electronic publications are now 2 months ahead of its print version and the difference will become greater.

• Researchers will pay to publish their articles (already occurring in Physics $2,000/article.)

• There is a new, more robust (100 Gbps) internet (http://www.internet2.edu/) in development.

As reported in the November 2005 OREF Bulletin:

http://www.hwbf.org/hwb/am2007/mankin_arc.pdf

Dr. Mankin has become heir to 3 substantial orthopaedic pathology collections covering over 75 years of the rare musculoskeletal disorders. This combined with his own collection, makes as many as 16,000 high quality teaching cases which are stored in his basement in Brookline.

As an indication of the historical significance and great personal sacrifice associated with the collection, Dr. Mankin recalled how in 1938, Dr. Erdheim, a world famous pathologist from the University of Vienna, just before the annexation of Austria and his murder by the Nazis, managed to salvage his portion of this collection by carefully rolling it in a rug and shipping it to Dr. Henry Jaffe in NY.

The current options are 1. to send the collections to be stored in Iron Mountain, possibly safe but lost to research. 2. to keep the collection in the basement and hope it stays dry. 3. Make the collections accessible on the web.

Dr. Mankin has started on the last approach and has now digitized about 25% of the collection. The approach taken has been to take the best slides and to include the correspondence of the sender and the pathologist’s response. However, it is a slow and exacting task and volunteers are always welcome. It has been recently complicated by having to comply with HIPAA statutes, but fortunately a software program has been developed which scrubs protected health information of all personal identifiers.

Dr. Mankin had to leave the meeting after his lecture, to give his orthopaedic basic science instructional course which he has done for the past 28 years.

Dr. Dohm, the leader of AAOS Outcomes Special Interest Group, provided a demonstration of a new "Evidence Based Practice" section of the AAOS Orthopaedic Knowledge Online which he and other colleagues involved in Outcomes Analysis have developed.

http://www5.aaos.org/oko/page1.cfm?pageID=OKO_EBP001_P1&topic=EBP001

Dr. Dohm noted the historical perspective provided by Dr. William Mallon

http://www5.aaos.org/oko/ebp/EBP001/suppPDFs/OKO_EBP001_S29.pdf

which described the contribution of EA Codman and the challenges he faced trying to get physicians to collaborate in the collection of end-result data. With the advent of the electronic medical record and other considerable technological advantages, are physicians any better prepared today to cooperate?

CMS, (Medicare & Medicaid), is beginning to realize that end result data collection for quality assurance needs incentives and is now starting to pay for follow-up information which has been CPT II and G modifier coded. The Physician Voluntary Reporting Program with CPT II and G Codes is an up and coming mechanism to motivate physicians to do outcome analysis.

see:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5036.pdf

http://www.hwbf.org/hwb/am2007/malchau/Registries_pro.htm

"Nothing spoils good results like follow-up"

Dr. Malchau is currently a leading developer one of the world's most sophisticated web based outcomes database - the MGH Harris Joint Registry.

http://www.orthojournalhms.org/volume7/manuscripts/ms20.htm

The Registry links to disparate data sources on the hospital network such as the OR schedule for demographics, OR bar code scanner for implant parameters, the EMR for clinical narratives, the PACS archive for xray images, the anesthesia database for OR times, anesthesia type, EBL, etc. . From our own attempts to do likewise, the HWB Foundation recognizes Dr. Malchau's informatics achievements as a political, academic and technical "tour de force". He reported on his well known work on the Swedish Arthroplasty Registry.

Sweden has become the world leader in registries and there are now 52 registries operating in Sweden. In Sweden in the 1990’s, the total hip revision rate was cut in half to 9.4%. The US has one of the highest revision rates in the world (17.4%) and being a much larger market, if the reduced revision rate was applied to the US there would be a budget saving of over $1 billion.

The main reasons for this success in Sweden were twofold: the feedback mechanism to the surgeons indicates which implants worked and which did not; the identification of which hospitals were getting poorer results. With this information and the fact that surgeons are both competitive and want to do well by their patients they will improve themselves. Today, porous coated implants are a tiny proportion of the Swedish Total Hip market yet for the rest of the world 1 in 4 stems is porous coated. In Sweden, the cups are primarily cemented, yet in the rest of the world they are primarily press fit porous coated. The registry and its feedback loop have identified problems early and often before they have been recognized elsewhere.

The Registry is now the main source of scientific data for decision support and public policy. Without a registry how do surgeons make decisions on what implant to use. There a number of alternatives; follow so called centers of excellence; market-based medicine; profit-based medicine.

Over the past 5 years there have been a number of other registries started in other countries and the trend is continuing. Australia has been one country that has been very active in this area in the past 5 years. The hip market has been enamored by the use of resurfacing products, but the Australian Registry is already showing much higher rates of early failure than found with other total hip options.

The Swedish Hip registry has collected data on approx. 250,000 hip procedures in 25 years. If the US could get a registry underway it would collect the same number of procedures in a single year!. The end point in the data is crude in that it is a revision procedure, but it is a very easily definable point, but will understate the actual number of poor results. Currently, the Swedish Registry has been pushing forward with links to hospitals electronic medical record and now less than 10% of the data is manually entered.

Due to other scheduling conflicts, Dr. Swiontkowski was unable to join the HWB meeting in time to make the case for focused studies instead of all inclusive registries. This link to a recent JBJS A editorial is provided as an expression of his point of view:

http://www.hwbf.org/hwb/am2007/why.pdf

http://www5.aaos.org/oko/page1.cfm?pageID=OKO_EBP001_P6&topic=EBP001

Dr. Putnam has been closely following his external fixation distal radius fractures using a registry of his own design. He feels that orthopaedic equipment manufacturing companies work in a similar fashion to those in automotive design. In a quote attributed to Charles Kettering of Memorial-Sloan-Kettering fame (actually head designer at General Motors during its hay-day. "The purpose of the engineering department is to sow dissatisfaction with the customers existing car so they will buy a new car" or "The key to economic prosperity is the organized creation of dissatisfaction".

There are 3 financial barriers to collection of data

Direct visit cost

Initial time cost

Benchmarking database cost.

There is a certain "paradigm blindness" that surgeons have to the collection and utilization of data. So far, Dr. Putnam has been able to show that the results he is obtaining with his external fixation are superior to those reported with volar plates and screws.

http://www.automationmed.com/emedoutcomes.htm

Dr. Goldstein has developed his own database using software that addresses his needs. He calls it E-Kiosk and the patient enters all their data into a computer when they arrive into his office. He has decided not to make it web compatible, as it reduces his concerns about someone breaking into the records. The patient can also fill out all the SF36 and the MF requirements.

Although he found initial development costs were higher, it has now significantly reduced costs and he has been able to eliminate one position in his office as a direct result of the use of the E-Kiosk. He feels that this is an easily manageable situation for a surgeon to do in private practice and he wishes more surgeons would be open-minded to the possibility.

The Meeting was adjourned at 2:15 PM.