2017 HSC Section 2 - Practice Management

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Practice Management

Home Study Course

Hsc Home Study Course

Section 2 November 2017

© 2017 American Academy of Otolaryngology—Head and Neck Surgery Foundation Empowering otolaryngologist-head and neck surgeons to deliver the best patient care

THE HOME STUDY COURSE IN OTOLARYNGOLOGY -- HEAD AND NECK SURGERY

SECTION 2

Practice Management

November 2017

SECTION FACULTY:

Scott E. Brietzke, MD MPH* David J. Brown, MD* Marina Boruk, MD Christina M. Gillespie, MD Johnathan McGinn, MD Gopi Shah, MD Betty S. Tsai, MD

American Academy of Otolaryngology - Head and Neck Surgery Foundation

2017 credit exam submission deadline: December 31, 2017 Section 2 suggested exam deadline: January 2, 2018 Expiration Date: August 7, 2018; CME credit not available after that date

Introduction The Home Study Course is designed to provide relevant and timely clinical information for physicians in training and current practitioners in otolaryngology - head and neck surgery. The course, spanning four sections, allows participants the opportunity to explore current and cutting-edge perspectives within each of the core specialty areas of otolaryngology. The Selected Recent Material represents primary fundamentals, evidence-based research, and state of the art technologies in practice management. The scientific literature included in this activity forms the basis of the assessment examination. The number and length of articles selected are limited by editorial production schedules and copyright permission issues, and should not be considered an exhaustive compilation of knowledge on practice management. The Additional Reference Material is provided as an educational supplement to guide individual learning. This material is not included in the course examination and reprints are not provided. Needs Assessment AAO-HNSF’s education activities are designed to improve healthcare provider competence through lifelong learning. The Foundation focuses its education activities on the needs of providers within the specialized scope of practice of otolaryngologists. Emphasis is placed on practice gaps and education needs identified within eight subspecialties. The Home Study Course selects content that addresses these gaps and needs within all subspecialties. Target Audience The primary audience for this activity is physicians and physicians-in-training who specialize in otolaryngology-head and neck surgery. Outcomes Objectives The participant who has successfully completed this section should be able to: 1. Recognize the changing nature of physician reimbursement systems, the structure of the otolaryngology workforce, and how these will affect the future of the specialty. 2. Discuss how performance metrics and electronic health records may be utilized to improve quality of care. 3. Identify those aspects of common otolaryngic care most susceptible to litigation and learn possible steps to reduce this risk. 4. Review current methods that can be utilized to improve communication in the healthcare setting as a means of error reduction. 5. Explain the concept of quality of care and how its measurement will affect physician compensation in the future. 6. Discuss the key elements of team medical care and the essential patient care handoff and understand the implications in potentially reducing medical errors. 7. Restate the essential issues involved when encountering the impaired or disruptive physician and learn strategies to successfully manage these challenging situations. 8. Review the factors associated with physician burnout and learn about existing tools and strategies designed to increase physician well-being and job-related satisfaction.

Medium Used The Home Study Course is available in electronic or print format. The activity includes a review of outcome objectives, selected scientific literature, and a self-assessment examination. Method of Physician Participation in the Learning Process The physician learner will read the selected scientific literature, reflect on what they have read, and complete the self-assessment exam. After completing this section, participants should have a greater understanding of practice management as well as useful information for clinical application. Accreditation Statement The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation The AAO-HNSF designates this enduring material for 40.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim credit commensurate with the extent of their participation in the activity. ALL PARTICIPANTS must achieve a post-test score of 70% or higher for a passing completion to be recorded and a transcript to be produced. Residents’ results will be provided to the Training Program Director. PHYSICIANS ONLY : In order to receive Credit for this activity a post-test score of 70% or higher is required. Two retest opportunities will automatically be available if a minimum of 70% is not achieved. Disclosure The American Academy of Otolaryngology Head and Neck Surgery/Foundation (AAO-HNS/F) supports fair and unbiased participation of our volunteers in Academy/Foundation activities. All individuals who may be in a position to control an activity’s content must disclose all relevant financial relationships or disclose that no relevant financial relationships exist. All relevant financial relationships with commercial interests 1 that directly impact and/or might conflict with Academy/Foundation activities must be disclosed. Any real or potential conflicts of interest 2 must be identified, managed, and disclosed to the learners. In addition, disclosure must be made of presentations on drugs or devices, or uses of drugs or devices that have not been approved by the Food and Drug Administration. This policy is intended to openly identify any potential conflict so that participants in an activity are able to form their own judgments about the presentation. [1] A “Commercial interest” is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. 2 “Conflict of interest” is defined as any real or potential situation that has competing professional or personal interests that would make it difficult to be unbiased. Conflicts of interest occur when an individual has an opportunity to affect education content about products or services of a commercial interest with which they have a financial relationship. A conflict of interest depends on the situation and not on the character of the individual. Estimated time to complete this activity: 40.0 hours

2017 Section 2: PRACTICE MANAGEMENT FACULTY

* Co-Chairs: Scott E. Brietzke, MD MPH, Pediatric Otolaryngology, Joe DiMaggio Children’s Hospital at Memorial, Hollywood, FL. Disclosure: No relationships to disclose. David J. Brown, MD, Associate Professor of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, Associate Dean and Associate Vice President for Health Equity and Inclusion Michigan Medicine, Ann Arbor, MI. Disclosure: No relationships to disclose. Faculty: Marina Boruk, MD, Assistant Professor, Director of Rhinology, Department of Otolaryngology-Head and Neck Surgery, SUNY Downstate Medical Center, Brooklyn, NY. Disclosure: Honoraria: Merck.

Christina M. Gillespie, MD, Partner, Ocean Otolaryngology, Toms River, NJ. Disclosure: No relationships to disclose

Johnathan D. McGinn, MD, Associate Professor, Otolaryngology Head & Neck Surgery, Residency Program Director, Division of Otolaryngology - Head & Neck Surgery, Penn State

Hershey Medical Center, Hershey, PA. Disclosure: No relationships to disclose.

Gopi Shah, MD, Assistant Professor, Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX. Disclosure: No relationships to disclose. Betty S. Tsai Do, MD, Assistant Professor, Associate Residency Program Director, Department of Otolaryngology Head and Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK. Disclosure: Other Intellectual: Advanced Bionics Corporation

Planner(s): Linda Lee, AAO─HNSF Education Program Manager Stephanie Wilson, Stephanie Wilson Consulting, LLC; Production Manager Richard V. Smith, MD, chair, AAO-HNSF Education Steering

No relationships to disclose No relationships to disclose

Expert Witness: various legal

Committee

firms

Brendan C. Stack, Jr., MD, chair, AAO-HNSF Core

Consulting Fee: Hollingsworth LLP; Shire Pharmaceuticals; Genentech Other Financial: Davies, Humphreys, Horton & Rees, PLC; Wright, Lindsey, Jennings, LLP

Otolaryngology & Practice Management Education Committee

This 2017-18 Home Study Course Section 2 does not include discussion of any drugs and devices that have not been approved by the United States Food and Drug Administration.

Disclaimer The information contained in this activity represents the views of those who created it and does not necessarily represent the official view or recommendations of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.

August 7, 2018: Deadline for all 2017-18 exams to be received; course closed August 8, 2018.

EVIDENCE BASED MEDICINE The AAO-HNSF Education Advisory Committee approved the assignment of the appropriate level of evidence to support each clinical and/or scientific journal reference used to authenticate a continuing medical education activity. Noted at the end of each reference, the level of evidence is displayed in this format: [EBM Level 3] .

Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) Level 1

Randomized 1 controlled trials 2 or a systematic review 3 (meta-analysis 4 ) of randomized controlled trials 5 . Prospective (cohort 6 or outcomes) study 7 with an internal control group or a systematic review of prospective, controlled trials. Retrospective (case-control 8 ) study 9 with an internal control group or a systematic review of retrospective, controlled trials. Case series 10 without an internal control group (retrospective reviews; uncontrolled cohort or outcome studies). Expert opinion without explicit critical appraisal, or recommendation based on physiology/bench research.

Level 2

Level 3

Level 4

Level 5

Two additional ratings to be used for articles that do not fall into the above scale. Articles that are informational only can be rated N/A , and articles that are a review of an article can be rated as Review. All definitions adapted from Glossary of Terms, Evidence Based Emergency Medicine at New York Academy of Medicine at www.ebem.org . 1 A technique which gives every patient an equal chance of being assigned to any particular arm of a controlled clinical trial. 2 Any study which compares two groups by virtue of different therapies or exposures fulfills this definition. 3 A formal review of a focused clinical question based on a comprehensive search strategy and structure critical appraisal. 4 A review of a focused clinical question following rigorous methodological criteria and employing statistical techniques to combine data from independently performed studies on that question. 5 A controlled clinical trial in which the study groups are created through randomizations. 6 This design follows a group of patients, called a “cohort”, over time to determine general outcomes as well as outcomes of different subgroups. 7 Any study done forward in time. This is particularly important in studies on therapy, prognosis or harm, where retrospective studies make hidden biases very likely. 8 This might be considered a randomized controlled trial played backwards. People who get sick or have a bad outcome are identified and “matched” with people who did better. Then, the effects of the therapy or harmful

exposure which might have been administered at the start of the trial are evaluated. 9 Any study in which the outcomes have already occurred before the study has begun. 10 This includes single case reports and published case series.

OUTLINE Section 2: Practice Management November 2017

I.

Practice Management A. Quality measures (definition, PQRS) B. Physician reimbursement (MACRA, MIPS) C. Otolaryngology workforce composition

II.

Professionalism A. Physician burnout B. Impaired physician C. Disruptive physician

III.

Communication A. Informed consent B. Telemedicine

IV.

Systems-Based Practice A. Electronic medical record B. Role of physician extenders (nurse practitioner, physician assistant) C. Team-based medicine (multi-disciplinary teams, handoffs)

V.

Practice-Based Learning A. Maintenance of certification B. Litigation data, lessons learned C. Role of mediation in resolving litigation

TABLE OF CONTENTS Selected Recent Materials - Reproduced in this Study Guide

SECTION 2: PRACTICE MANAGEMENT November 2017

ADDITIONAL REFERENCE MATERIAL .......................................................................................i - iv

I.

Practice Management A. Quality measures (definition, PQRS) Bekelis K, McGirt MJ, Parker SL, et al. The present and future of quality measures and public reporting in neurosurgery. Neurosurg Focus . 2015; 39(6):E3. EBM level NA............................................................................................................................1-7 Summary : This article summarizes recent changes to physician reimbursement that have been implemented by Centers for Medicare and Medicaid Services (CMS) and those that are in process. Specifically, the authors review how quality is defined and how the changes affect physician practices. The article discusses the use of registries, certified electronic health record technology (CEHRT), and Value-Based Payment Modifier (VM) in determining physician fee schedules. Last, it discusses how the Medicare Access and CHIP Reauthorization Act (MACRA) will use the Merit-Based Incentive Payment System (MIPS) to determine bonus payments and penalties. Vila PM, Schneider JS, Piccirillo JF, Lieu JE. Understanding quality measures in otolaryngology-head and neck surgery. JAMA Otolaryngol Head Neck Surg . 2016; 142(1):86-90. EBM level 5............................................................................................8-12 Summary : This article explores pay-for-performance models in otolaryngology. The article covers historical development, various models, and approaches to creating effective performance measures. B. Physician reimbursement (MACRA, MIPS) Miller P, Mosley K. Physician reimbursement: from fee-for-service to MACRA, MIPS and APMs. J Med Pract Manage . 2016; 31(5):266-269. EBM level NA.................13-16 Summary : This article provides information on how healthcare reimbursement has changed over the years, with a focus on the upcoming changes as outlined by the Medicare Access and CHIP Reauthorization Act (MACRA) and how it would impact physician reimbursement. The authors provide an overview of the Merit-Based Incentive Payment System (MIPS) as well as Alternative Payment Models (APMs).

C. Otolaryngology workforce composition Hughes CA, McMenamin P, Mehta V, et al. Otolaryngology workforce analysis. Laryngoscope . 2016; 126 Suppl 9:S5-S11. EBM level NA.......................................17-23 Summary : This article evaluates several database sources regarding the supply and demand of otolaryngologists in the United States. The article concludes that the available workforce is below the forecasted needs in future years for the U.S. population. The demographics of the workforce and data reporting the most common diagnoses reported during otolaryngology visits are also presented. Fletcher AM, Pagedar N, Smith RJ. Factors correlating with burnout in practicing otolaryngologists. Otolaryngol Head Neck Surg . 2012; 146(2):234-239. EBM level 4...........................................................................................................................24-29 Summary : This is a comprehensive study of burnout among practicing ENTs, and is not just focused on academic ENTs. The study showed that younger age, hours worked per week, and fewer years in practice were the most significant predictors of burnout, whereas length of time in marriage was protective. Similar to other studies, findings indicated having children in the family also contributed to burnout. Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg . 2014; 259(1):82-88. EBM level 4................................................................................30-36 B. Impaired physician DesRoaches CM, Rao SR, Fromson JA, et al. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA . 2010; 304(2):187-193. EBM level 4............................................................................37-43 Summary : Self-policing of physicians is a keystone mechanism for the profession in identifying and managing impaired or incompetent providers. This large survey study found that more than 40% of physicians did not completely agree with the professional responsibility to report. While a majority of respondents (64%) felt well prepared to address an impaired colleague, 17% report having failed to report direct knowledge of an impaired or incompetent physician in the last 3 years. The report indicated the need to better educate physicians on the importance of reporting impaired colleagues as a patient safety issue and to reduce concerns of retribution or personal loss from reporting. This is an older paper, but high quality. Professionalism A. Physician burnout Summary : Surgeons do not self-assess their distress level well. Validated self-assessment tools may help promote changes to improve personal well-being.

II.

C. Disruptive physician Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg . 2014; 219(3):390-398. EBM level 4.........................44-52 Summary : This paper presents a study at a single institution involving several types of operating room participants regarding disruptive surgeon behavior. The article focuses on characterizing types of disruptive behavior. The authors found situational stress tended to increase disruptive behavior.

Grogan MJ, Knechtges P. The disruptive physician: a legal perspective. Acad Radiol . 2013; 20(9):1069-1073. EBM level 5..........................................................................53-57

Summary : Disruptive behavior has cascading effects in the functioning and safety of the medical care team. Loss of privileges is a reasonable action by hospitals faced by disruptive physician behavior, but such action must follow some key policies.

Overton AR, Lowry AC. Conflict management: difficult conversations with difficult people. Clin Colon Rectal Surg . 2013; 26(4):259-264. EBM level NA....................58-63

Summary : This article provides strategies on how to deal with conflict within the workplace. It discusses approaches to preparing for the conflict discussion, proceeding with the discussion, and responding to conflict management. The authors also describe how to deal with the disruptive physician.

III.

Communication A. Informed consent

Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. J Am Coll Surg . 2009; 208(4):627-634. EBM level 5............................................................................64-71

Summary : While this article is older, it provides a great overview of the key components and concepts in informed consent as it applies to the surgeon. Several key common challenges to full informed consent are discussed and options are reviewed. Kraft SA, Constantine M, Magnus D, et al. A randomized study of multimedia informational aids for research on medical practices: implications for informed consent. Clin Trials . 2017; 14(1):94-102. EBM level 1...........................................................72-80 Summary : Understanding of research issues and concepts are important for participants’ understanding of the research and proper consent. This study evaluates the use of multimedia aids vs. text-only information on these concepts. Text-only information performed worst amongst options for information conveyance. While the article is geared to clinical research informed consent, some applicability also likely exists in clinical informed consent.

Pianosi K, Gorodzinsky AY, Chorney JM, et al. Informed consent in pediatric otolaryngology: what risks and benefits do parents recall? Otolaryngol Head Neck Surg . 2016; 155(2):332-339. EBM level 4............................................................................81-88 Summary : This article presents results of a study of how well parents recalled informed consent regarding tonsillectomy, adenoidectomy, and tube placement 2 weeks after the in-office discussion. Both the in-office discussion and the phone call with the recall questions were recorded and compared. Although there was significant variability among providers as to what was included in the informed consent, it was noted that parents electing surgery tended to remember more benefits than risks. Additionally, there were parents who recalled risks and benefits that were not discussed, suggesting that they were seeking outside sources in addition to the office visit. B. Telemedicine Beswick DM, Vashi A, Song Y, et al. Consultation via telemedicine and access to operative care for patients with head and neck cancer in a Veterans Health Administration population. Head Neck . 2016; 38(6):925-929. EBM level 3............89-93 Summary : Telemedicine is increasingly being utilized as a healthcare delivery model for complex subspecialty care in remote patient populations. Head and neck cancer is a complex disease that is optimally treated with a multidisciplinary care team and a well- developed infrastructure. Therefore, telemedicine has been proposed as a mechanism to facilitate treatment of head and neck cancer for patients who reside at a significant distance from such a center. It has been noted that in addition to facilitating timely access to subspecialty surgical care, the developed telemedicine protocol enabled significant travel-related time savings and financial savings for patients.

Hasan H, Ali F, Barker P, et al. Evaluating handoffs in the context of a communication framework. Surgery . 2017; 161(3):861-868. EBM level 2b...................................94-101

Summary : Handoffs refer to the transfer of patient care between healthcare providers. Changes in residency work hours have resulted in an increased number of handoffs. This study examines factors that can negatively impact the handoff. Also, the information from the study allows for targeted interventions to improve the handoff process and hopefully patient care.

Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient engagement: a state of the science review. J Med Internet Res . 2015; 17(6) e148. EBM level 5.........102-116

Summary : This is review article on patient portals. The article reviews factors that influence patient use of patient portals. Studies on patient portals were grouped into one of five categories: patient adoption, provider endorsement, health literacy, usability, and utility. Principal findings revealed that the CMS and Medicaid EHR incentive program is the major driver of patient portal development. The study concludes that adoption by patients and providers will come when existing patient portal features align with the needs of patients and providers.

Przybylo JA, Wang A, Loftus P, et al. Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med. 2014; 9(9):573-578. EBM level 3b.................................117-122

Summary : This article presents a comparison of paging to smartphone texting to improve provider perception of communication.

IV.

Systems-Based Practice A. Electronic medical record

Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systemic review and meta-analysis. Syst Rev . 2014; 3:56. EBM level 3a......................................................................................................................123-134 Summary : This meta-analysis of 16 studies shows that computerized order entries reduce preventable adverse drug events and medication errors by 50% compared to written orders, despite the type of EMR system. B. Role of physician extenders (nurse practitioner, physician assistant) Bhattacharyya N. Involvement of physician extenders in ambulatory otolaryngology practice. Laryngoscope . 2012; 122(5):1010-1013. EBM level 2b........................135-138 Summary : This article uses a large national database to determine the prevalence of care provided by an advanced practice clinician (APC) in an outpatient ENT practice, the visit type, and common diagnoses the APC treats. Between 2008-09, approximately 6% of these visits were with a physician assistant (PA) or nurse practitioner (NP), and NPs were more likely to see patients independently (47%) than PAs (23%). Most were established patient visits for disorders of external or middle ear. Norris B, Harris T, Stringer S. Effective use of physician extenders in an outpatient otolaryngology setting. Laryngoscope . 2011; 121(11):2317-2321. EBM level 5.......................................................................................................................139-143 Summary : This article clearly defines five practice models (or different levels of practice) for the incorporation of advanced practice providers in an outpatient ENT setting to improve efficiency, patient education, and patient care. C. Team-based medicine (multi-disciplinary teams, handoffs) Lee SH, Phan PH, Dorman T, et al. Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. BMC Health Serv Res . 2016; 16:254. EBM level 3b............................................................................................................144-151 Summary : This study was performed with data from a 2010 survey. The study examined the relationships between perceptions of handoffs, patient safety culture, and patient safety. The study showed staff views on the behavioral dimensions of handoffs influenced their perceptions of the hospital’s level of patient safety.

Richter JP, McAlearney AS, Pennell ML. The influence of organizational factors on patient safety: examining successful handoffs in health care. Health Care Manage Rev . 2016; 41(1):32-41. EBM level 3b............................................................................152-161

Summary : This article presents an analysis of how teamwork across units improves communication and handoffs.

Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg . 2013; 258(6):856-871. EBM level 3a................................................................................162-177 Summary : This article is a systematic review of 20 articles on the effect of safety checklists on teamwork/communication in the operating room. The authors found that there is a perceived improvement on teamwork and communication; however, conversely, when individuals have not “bought in” to the process, this may have a negative effect on the team. Shams A, Ahmed M, Scalzitti NJ, et al. How does TeamSTEPPS affect operating room efficiency? Otolaryngol Head Neck Surg . 2016; 154(2):355-358. EBM level 3b.....................................................................................................................178-181 Summary : TeamSTEPPS is a patient safety tool developed by the Dept. of Defense and the Agency for Healthcare Research and Quality to improve communication and teamwork among healthcare teams. In the morning, 30 minutes prior to first case, the operating room (OR) team–surgeon, anesthesiologist/CRNA, nurse, and OR tech–are present to go through the day’s cases, and then debriefs occur at the end of every case. This study looks at efficiency of the OR with the implementation of TeamSTEPPS and finds that there is no difference between OR efficiency (turnover times, first start times, and operative times) when comparing before and after implementation of TeamSTEPPS in the ENT OR. Cook DA, Blachman MJ, West CP, Wittich CM. Physician attitudes about maintenance of certification: a cross-specialty national survey. Mayo Clin Proc . 2016; 91(10):1336- 1345. EBM level 4...................................................................................................182-191 Summary : Each member board of the American Board of Medical Specialties has developed an maintenance of certification (MOC) program addressing professional standing, lifelong learning and self-assessment, assessment of knowledge and skills, and improvement in medical practice. Maintenance of certification has a sound theoretical rationale, is favorably associated with some clinical quality measures, and many physicians support its intent, yet substantive concerns have been raised about the effectiveness, relevance, and value of current MOC programs. A cross-specialty national survey of U.S. physicians was conducted to determine physicians’ perceptions of current MOC activities and to explore how their perceptions vary across specialties, practice models, certification status, and level of burnout.

V.

Practice-Based Learning A. Maintenance of certification

B. Litigation data, lessons learned Stevenson AN, Myer CM 3rd, Shuler MD, Singer PS. Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope . 2012; 122(1):71-74. EBM level 4.......................................................................................................................192-195 Summary : This article reports on the contents of the LexisNexis legal database regarding tonsillectomy cases that were litigated or settled from 1984 to 2010. Verdicts and monetary awards were analyzed for trends and common themes in the causes of complications, litigation, and outcome. The article then presents key learning points for the otolaryngologist to avoid or reduce the risk of future litigation involving tonsillectomy patients. Svider PF, Carron MA, Zuliani GF, et al. Lasers and losers in the eyes of the law: liability for head and neck procedures. JAMA Facial Plast Surg . 2014; 16(4):277-283. EBM level 4..............................................................................................................196-202 Summary : Procedures using lasers represent a potential target for malpractice litigation when an adverse event occurs. Although otolaryngologists were more likely to be named as physician defendants when lasers were used in head and neck interventions, cases in this analysis included cutaneous/cosmetic procedures as well. The importance of the informed consent process was emphasized. Winford TW, Wallin JL, Clinger JD, Graham AM. Malpractice in treatment of sinonasal disease by otolaryngologists: a review of the past 10 years. Otolaryngol Head Neck Surg . 2015; 152(3):536-540. EBM level 4........................................................................203-207 Summary : Otolaryngologists should be knowledgeable of the reasons for litigation in the treatment of sinonasal disease as well as the importance of informed consent. This article reviews the recent trends and causes for litigation, outcomes of such suits, and legal requirements in a medical malpractice case. C. Role of mediation in resolving litigation Sohn DH, Bal BS. Medical malpractice reform: the role of alternative dispute resolution. Clin Orthop Relat Res . 2012; 470(5):1370-1378. EBM level 4.............................208-216 Summary : The U.S. healthcare system needs reform. The current tort system is extremely expensive. This article explores alternative dispute resolution (ADR) as a technique to help reform the current tort system. ADR has an excellent track record of avoiding litigation, decreasing overall cost, and increasing satisfaction among both plaintiffs and defendants.

2017-18 SECTION 2: PRACTICE MANAGEMENT ADDITIONAL REFERENCES

Anoushiravani AA, Patton J, Sayeed Z, et al. Big data, big research: implementing population health- based research models and integrating care to reduce cost and improve outcomes. Orthop Clin North Am . 2016; 47(4):717-724.

Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg . 2005; 190(5):770-774.

Ban VS, Madden CJ, Browning T, et al. A novel use of the discrete templated notes within an electronic health record software to monitor resident supervision. J Am Med Inform Assoc . 2017; 24(e1):e2-e8.

Barinaga G, Chambers MC, El-Othmani MM, et al. Affordable care organizations and bundled pricing: a new philosophy of care. Orthop Clin North Am . 2016; 47(4):707-716.

Batra PS. Evidence-based practice: balloon catheter dilation in rhinology. Otolaryngol Clin North Am . 2012; 45(5):993-1004.

Boyd JW. Deciding whether to refer a colleague to a physician health program. AMA J Ethics . 2015; 17(10):888-893.

Camp MW, Mattingly DA, Gross AE, et al. Patients’ views on surgeons’ financial conflicts of interest. J Bone Joint Surg Am . 2013; 95(2):e9 1-8.

Casalino LP, Wu FM, Ryan AM, et al. Independent practice associations and physician-hospital organizations can improve care management for smaller practices. Health Aff (Millwood) . 2013; 32(8):1376-1382.

Catchpole KR, Dale TJ, Hirst DG, et al. A multicenter trial of aviation-style training for surgical teams. J Patient Saf . 2010; 6(3):180-186.

Chang CWD, Mills JC. Effects of a reward system on resident research productivity. JAMA Otolaryngol Head Neck Surg . 2013; 139(12):1285-1290.

Choudhri AF, Chatterjee AR, Javan R, et al. Security issues for mobile medical imaging: a primer. Radiographics . 2015; 35(6):1814-1824.

Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. Am J Surg . 2015; 209(1):65-70.

Colla CH, Lewis VA, Shortell SM, Fisher ES. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff (Millwood) . 2014; 33(6):964-971.

Contrera KJ, Ishii LE, Setzen G, Berkowitz SA. Accountable care organizations and otolaryngology. Otolaryngol Head Neck Surg . 2015; 153(2):170-174.

Date DF, Sanfey H, Mellinger J, Dunnington G. Handoffs in general surgery residency, an observation of intern and senior residents. Am J Surg . 2013; 206(5):693-697.

i

Delisle M, Grymonpre R, Whitley R, Wirtzfeld D. Crucial conversations: an interprofessional learning opportunity for senior healthcare students. J Interprof Care . 2016; 30(6):777-786.

Dewa CS, Loong D, Bonato S, et al. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res . 2014; 14:325.

Dupree JM, Patel K, Singer SJ, et al. Attention to surgeons and surgical care is largely missing from early Medicare accountable care organizations. Health Aff (Millwood) . 2014; 33(6):972-979.

Dyrbye LN, West CP, Satele D, et al. A national study of medical students’ attitudes toward self- prescribing and responsibility to report impaired colleagues. Acad Med . 2015; 90(4):485-493.

Evidence-Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA . 1992; 268(17):2420-2425.

Espinel AG, Shah RK, Beach MC, Boss EF. What parents say about their child’s surgeon: parent- reported experiences with pediatric surgical physicians. JAMA Otolaryngol Head Neck Surg . 2014; 140(5):397-402. Falcone JL, Claxton RN, Marshall GT. Communication skills training in surgical residency: a needs assessment and metacognition analysis of a difficult conversation objective structured clinical examination. J Surg Educ . 2014; 71(3):309-315.

Fischer T, Brothers KB, Erdmann P, Langanke M. Clinical decision-making and secondary findings in systems medicine. BMC Med Ethics . 2016; 17(1):32-44.

Furukawa MF, King J, Patel V, et al. Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood) . 2014; 33(6):1672-1679.

Grady C. Enduring and emerging challenges of informed consent. N Engl J Med . 2015; 372(9):855-862.

Haider AH, Obirieze A, Velopulos CG, et al. Incremental cost of emergency versus elective surgery. Ann Surg . 2015; 262(2):260-266.

Harle CA, Cook RL, Kinsell HS, Harman JS. Opioid prescribing by physicians with and without electronic health records. J Med Syst . 2014; 38(11):138-144.

Higgins A, Veselovskiy G, McKown L. Provider performance measures in private and public programs: achieving meaningful alignment with flexibility to innovate. Health Aff (Millwood) . 2013; 32(8):1453- 1461.

Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children. Can J Surg . 2009; 52(4):309-315.

Kim JS, Cooper RA, Kennedy DW. Otolaryngology-head and neck surgery physician work force issues: an analysis for future specialty planning. Otolaryngol Head Neck Surg . 2012; 146(2):196-202.

Koltov MK, Damle NS. Health policy basics: Physician Quality Reporting System. Ann Intern Med . 2014; 161(5):365-367.

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Reprinted by permission of Neurosurg Focus. 2015; 39(6):E3.

neurosurgical focus

Neurosurg Focus 39 (6):E3, 2015

The present and future of quality measures and public reporting in neurosurgery Kimon Bekelis, MD, 1 Matthew J. McGirt, MD, 2 Scott L. Parker, MD, 3 Christopher M. Holland, MD, PhD, 4 Jason Davies, MD, PhD, 5 Clinton J. Devin, MD, 6 Tyler Atkins, MD, 2 Jack Knightly, MD, 7 Rachel Groman, MPH, 8 Irene Zyung, BA, 9 and Anthony L. Asher, MD 2 1 Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; 2 Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina; Departments of 3 Neurosurgery and 6 Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; 4 Department of Neurosurgery, University of Utah, Salt Lake City, Utah; 5 Department of Neurological Surgery, State University of New York at Buffalo, New York; 7 Department of Neurological Surgery, Atlantic Neurosurgical Specialists, Morristown, New Jersey; 8 Clinical Affairs and Quality Improvement, Hart Health Strategies, Inc., Washington, DC; and 9 American Association of Neurological Surgeons, Rolling Meadows, Illinois Quality measurement and public reporting are intended to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. However, regulatory implementation has created a complex network of reporting requirements for physicians and medical practices. These include Medicare’s Physician Quality Reporting System, Electronic Health Records Meaningful Use, and Value-Based Payment Modifier programs. The common denominator of all these initiatives is that to avoid penalties, physicians must meet “generic” quality stan- dards that, in the case of neurosurgery and many other specialties, are not pertinent to everyday clinical practice and hold specialists accountable for care decisions outside of their direct control. The Centers for Medicare and Medicaid Services has recently authorized alternative quality reporting mechanisms for the Physician Quality Reporting System, which allow registries to become subspecialty-reporting mechanisms under the Qualified Clinical Data Registry (QCDR) program. These programs further give subspecialties latitude to develop mea- sures of health care quality that are relevant to the care provided. As such, these programs amplify the power of clinical registries by allowing more accurate assessment of practice patterns, patient experiences, and overall health care value. Neurosurgery has been at the forefront of these developments, leveraging the experience of the National Neurosurgery Quality and Outcomes Database to create one of the first specialty-specific QCDRs. Recent legislative reform has continued to change this landscape and has fueled optimism that registries (including QCDRs) and other specialty-driven quality measures will be a prominent feature of federal and private sector quality improvement initiatives. These physician- and patient-driven methods will allow neurosurgery to underscore the value of interventions, contribute to the development of sustainable health care solutions, and actively participate in meaningful quality initiatives for the benefit of the patients served. http://thejns.org/doi/abs/10.3171/2015.8.FOCUS15354 Key Words  quality measures; value; Physician Quality Reporting System; Qualified Clinical Data Registry; Centers for Medicare and Medicaid Services

Abbreviations  CEHRT = certified EHR technology; CMS = Centers for Medicare and Medicaid Services; EHR = electronic health record; EP = eligible professional; MACRA = Medicare Access and CHIP Reauthorization Act; MIPS = Merit-Based Incentive Payment System; NQF = National Quality Forum; N 2 QOD = National Neurosur- gery Quality and Outcomes Database; PQRS = Physician Quality Reporting System; QCDR = Qualified Clinical Data Registry; VM = Value-Based Payment Modifier.

submitted  July 22, 2015.  accepted  August 18, 2015. include when citing  DOI: 10.3171/2015.8.FOCUS15354.

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uality measurement has taken on an increasingly central role in our rapidly evolving health care landscape. 7 As the practice of medicine shifts from individual authority to societal accountability, the qual- ity of medical interventions will be under increasing and continuous scrutiny by patients, peers, payers, and policy makers. 7 If executed appropriately, quality measurement can em- power all members of the health care equation. 7 First, the accumulation of high-quality, risk-adjusted data advances the objective of patient-centered health care by giving pa- tients the tools to participate more meaningfully in shared decision making. Second, physicians and other health care professionals will be able to use these data to facilitate tar- geted quality improvement, practice-based learning, and effective resource utilization. Third, the data will allow policy makers and payers to more easily and accurately understand the true value of clinical interventions, an es- sential consideration in resource-intensive fields such as neurosurgery. In the end, better data will allow these vari- ous stakeholders to reward clinical excellence in an objec- tive and evidence-based manner. The Importance of Quality Measurement in Medicine Now more than ever, there is increasing regulatory pressure to create a standardized framework for quality measurement across all areas of medicine. The Centers for Medicare and Medicaid Services (CMS) developed and released the CMS quality strategy in 2013 13 in alignment with the National Quality Strategy. 1 The CMS quality programs address care provided across the continuum, en- courage quality improvement through the use of payment incentives and reductions, and promote transparency. Although these goals are well intentioned, most national quality metrics developed to date have been generic and do not reflect the needs of specialty medicine or mean- ingfully improve care. Furthermore, measures often rely solely on administrative (claims) data, which for special- ties such as neurosurgery lack specificity due to coding limitations. In this environment, neurosurgery can play a pivotal role in the advancement of health care quality and safety through the creation of more robust, data-driven, specialty-specific measures. We present here an overview of the current quality measurement and reporting landscape with an emphasis on new regulatory and legislative developments, such as the Physician Quality Reporting System (PQRS) Quali- fied Clinical Data Registry (QCDR) reporting option. We highlight the role of neurosurgery and new opportunities in this rapidly changing field. Quality Measures Quality measures are used to determine the value of care provided by physicians; they are tools that help quan- tify health care processes, outcomes, patient perceptions, organizational structure, and systems of care. Measures are meant to reflect the ability of physicians and clinical teams to provide high-quality care. The CMS has estab-

lished that quality measures should relate to one or more of the following goals: effective, safe, efficient, patient- centered, equitable, and timely care. 17 The types of measures reported change yearly. 17 They generally vary by specialty and focus on quality areas such as clinical outcomes, care coordination, patient safety and engagement, clinical processes, effectiveness of care, and population/public health. They can also vary by reporting method. In order for quality measures to be considered relevant to specific clinical conditions and to be selected for use, the following factors are considered: type of care delivered (e.g., preventive, chronic, acute); clinical setting in which care is delivered (e.g., office, emergency depart- ment, operating room); quality improvement goals for the given year; as well as other quality reporting programs in use. 17 The most common measure types are outcome, process, and structural measures. They are defined as follows: 17 1) outcome measure: a measure that assesses the results of health care experienced by patients such as clinical events, recovery and health status, experiences in the health sys- tem, and efficiency/costs of care; 2) process measure: a measure that focuses on steps that should be followed to provide good care—these measures are predicated upon the belief that a scientific basis exists to support the con- clusion that the process, when executed according to de- sign, will increase the probability of achieving a desired outcome; and 3) structural measure: a measure that assess- es features of a health care organization or clinician rel- evant to the capacity to provide quality health care. These measures address the resources and capabilities available for patient care. Quality Measure Development There are several ways new quality measures may be- come accepted. National or regional organizations, pri- vate or public vendors, and professional societies or asso- ciations are all actively participating in the development process. Measure validation and approval by expert mul- tidisciplinary panels lie at the core of creating high-quali- ty metrics. Some of the highest standards for the develop- ment and maintenance of quality metrics have been set by the National Quality Forum (NQF). 28 Most developers must put their measures through a rigorous evaluation process long before the NQF considers them for endorse- ment. This organization’s careful review and assessment gathers input from stakeholders across the health care enterprise and develops consensus about which measures warrant endorsement as “best in class.” The NQF uses 4 criteria to assess a measure for endorsement. Proposed measures should be 1) important to report, 2) scientifi- cally acceptable, 3) useable and relevant, and 4) feasible to collect. 28 Despite its rigor, the NQF process can be lengthy and expensive. The NQF review process typically occurs on a 3-year schedule. 26 Every 3 years, endorsed measures in a topical area, as well as newly submitted measures, un- dergo a 9-step consensus development process, including review against updated NQF evaluation criteria, to ensure that the measure specifications are current, accurate, and

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