Dr. John Dietz, Board Chairman of the Indiana Orthopaedic Hospital, Discusses 10 Trends in Hospital Orthopedics

John Dietz, MD, board chairman at the Indiana Orthopaedic Hospital in Indianapolis, describes the current climate regarding healthcare as a "period of great flux and uncertainty." From the economic downfall and recession to political issues such as cuts in healthcare spending and healthcare reform, many changes and challenges are facing a variety of programs in the hospital setting.

Orthopedics, which remains a high-reimbursement and high-cost specialty, is experiencing many similar trends to other specialties in the hospital setting as well as some unique to orthopedics.

Here are 10 trends and what they could mean for orthopedics in hospitals.

1. Increased demand for orthopedists
As the Baby Boomer generation ages, orthopedists could see many benefits but also face some potential challenges, according to Dr. Dietz.

"There currently is an increasing demand for orthopedists due to an aging population," he says. Additionally, this aging population also depends on orthopedists to take care of them in such a way that they can quickly return to their normal level of activity, as opposed to the type of patient surgeons had seen in the past.

"People may be aging but they want to remain active," Dr. Dietz says. "Regardless of age, everyone is busy. Patients have high expectations for quick access to specialty care, extraordinary quality care and rapid return to normal level of activity. Quality programs focus on exceeding these expectations."

2. Pool of qualified orthopedists is declining
Dr. Dietz sees a decline in the supply of highly-trained orthopedic surgeons, which could cause problems as the current pool of physicians ages. "Too few orthopedic surgeons are being trained. Most residency graduates now go on to subspecialty fellowship training for another year or two after their five-year residency and four years of medical school," he says.

Meanwhile, practicing orthopedists face increasing costs and lower reimbursement, forcing some to choose between retiring early or becoming employed by hospitals.  "Orthopedic surgery is not a commodity," Dr. Dietz says. "You can't just get on the phone and order up a bushel of new orthopedic surgeons. This is a long-term issue that may affect both access and quality.

"Patients and surgeons must ask themselves: 'Where will the new surgeons come from'; 'Where will they practice'; and 'Who will train them?' A key issue in the next decade may be access to quality orthopedic care," he says.

3. Costs are increasing while reimbursement is decreasing
Reimbursement and professional fees for orthopedic surgery have been declining while costs have been increasing, which can have significant hit on orthopedics programs in the hospitals. Programs must work to identify ways to keep costs as low as possible to offset the decline in payment.

"It is important to take a proactive approach to holding down cost," Dr. Dietz says. He notes that his hospital, which is nearly 100 percent physician owned, has tried to "build systems that are efficient and cost less." These have included creating quicker turnaround times so surgeons can see more patients.

4. Standardizing procedures, specialized training for staff can help control costs
One change undertaken by Indiana Orthopaedic Hospital to keep costs down is to standardize procedures among the surgeons. "There are multiple ways of achieving the same clinical outcomes," Dr. Dietz says. "We try to simplify procedures, such as techniques in the OR and the overall [process] of care of patients. For example, we have a pulmonologist whose team sees all of our patients pre-op. Also, post-op, he manages all of the patients' medical problems, so there is continuity of medical care. The surgeons are free to do more of what they are good at — surgery."

By simplifying this process instead of referring patients to multiple physicians for pre- and post-op care, Dr. Dietz's hospital is able to keep its costs down and reduces the risks for patients postoperatively because the same physician has seen them both before and after surgery.

Dr. Dietz also notes that having a nursing staff uniquely trained for orthopedics helps to simplify processes and eliminate errors. "Nurses at IOH are highly trained orthopedic nurses," he says. "We only attract nurses whose main interest is orthopedic patients. They get further training from other nurses who are experts in this field. Best of all, no orthopedic patient is ever cared for by a nurse from a different field. There is no chance for an ENT nurse, for example, to get assigned to the orthopedic floor because of staffing shortages. Everyone at IOH is specialized."

5. Rising implant costs are cause for concern
The extensive use of implants for orthopedic surgeries on the aging patient population is one area driving the rising costs for orthopedists in hospitals. While some hospitals have tried to cut down on costs by standardizing the implants their surgeons can use, Dr. Dietz says limiting the choices of surgeons may not be the best solution to the problem. Instead, he recommends engaging the surgeons in an analysis of the value of spending more on new implants by balancing the possible benefit against the increased cost.

"No administrator has the experience to make such a judgment although every administrator feels the effect of more expensive implants. In some cases, the expense may be justified, but in other cases it may not. Surgeon and administration collaboration helps make decisions which benefit the patient," he says.

6. Surgeries are becoming less invasive, faster
All patients are looking for smaller, less-invasive procedures and shorter hospital stays in order to stay active. Orthopedic research has helped meet this demand through improvement on arthroscopic and minimally invasive procedures, according to Dr. Dietz. 

Many patients who are electing to come in for orthopedic surgery have concerns regarding the amount of time they will be required to take off of work for the procedure, Dr. Dietz notes. Many of these fears come as a result of the economy. Some patients worry that if they take too much time off of work, their job could be in jeopardy. Others are concerned about costs or want to have surgery completed before their health insurance coverage runs out.

"Many patients are intent on getting things fixed in order to get back to work," says Dr. Dietz. "Although most orthopedics procedures are elective, some patients find them necessary to stay on the job." These surgeries include fixing knee or back problems that have affected a worker's productivity.

Minimally invasive surgery technology has helped orthopedic surgeons to achieve the quicker surgery and recovery times that patients are looking for. "Arthroscopic surgery can now be performed on just about every joint you can imagine," Dr. Dietz says.

Arthroscopy, which was developed for use in the knee, has now replaced many shoulder, hip, ankle and elbow incisions with tiny portals, according to Dr. Dietz.

"In the spine, use of microscopes, high-tech retractors and new imaging technology has fostered an explosion in minimally invasive techniques," Dr. Dietz says. "Even some joint replacement surgery is now done through tiny incisions."

Spine surgery and total joint replacement have also seen great advances, according to Dr. Dietz. These range from microsurgery for herniated discs to doing back fusions through tiny incisions. Total joint surgeons are perfecting partial joint replacements with smaller and smaller operations. These smaller surgeries result in less postoperative pain, less time off work and fewer complications, which satisfies both the patient and the surgeon.

Computer-guided surgery, another new surgical technique used in spine and joint replacement surgeries, allows surgeons to see a CT scan of the surgical area on a screen during the procedure. "This enables the surgeon to see the position of the tool inside the surgical area," Dr. Dietz says. "This technique gives the surgeon more visibility and makes the surgery safer as a result."

Dr. Dietz also sees these advances as steps toward meeting the goals of healthcare reform in the United States. The benefits of these minimally invasive surgeries are that patients and surgeons are seeing shorter and smaller surgeries, lower complication rates and shorter hospital stays.

7. Growing dependence on EMR
Using electronic medical records is a way in which orthopedic programs in hospitals can keep costs down while maintaining a high level of patient care, according to Dr. Dietz.

Dr. Dietz's hospital started using EMR in 2005, and the switch allowed the program to save the facility money when it went fully electronic and completely paperless. "We don't run two systems in parallel like many hospitals," he says. "We use computerized physician order entry as well as digital physician progress notes. There is no paper record to get lost or messed up. Our imaging is also fully digital so we can access X-rays, MRIs and CTs from anywhere and films don't get lost like they used to.

"EMR enables everything to be recorded in one system: patient records, imaging records, physician entries" Dr. Dietz adds. "This offers the continued possibility of increased safety and efficiency going forward."

8. Need for greater collaboration
Dr. Dietz notes that the collaboration that takes place among surgeons, other physicians, nurses, therapists and technicians at IOH helps to maintain this efficiency. "The doctors are highly motivated to help make IOH run better," he says. "I often say it's like the difference between owning your home and renting your home. You may take good care of a rented home, but when you own the house, there is a whole new level of commitment."

Dr. Dietz suggests that surgeons performing orthopedics in the hospital setting can keep costs down by meeting on a regular basis and examining all aspects of their procedures to see what is effective and ineffective in keeping costs down. For example, at the IOH, Dr. Dietz say certain groups of physicians, such as those who perform total joint services or spine surgeons, meet and look at everything from the prophylaxis they use to the disposables and see what can be improved to hold down costs.

9. Customer service remains key to success
The patient's experience is critical in the continued success of an orthopedic specialty in the hospital setting. Dr. Dietz says that keeping attention focused on the patient leads to great customer service.

"The reality today is that patients, hospitals and orthopedic surgeons have to thrive in an uncertain time," he says. "For all, the key to survival is customer service."

Many hospitals have focused on creating an individualized patient experience that keeps patients comfortable while enhancing their recovery and care while at the hospital. "We've tried to maximize comfort in our patient rooms," Dr. Dietz says. At IOH, the design of the hospital tries to minimize noise for recovering patients. Also, each patient has a private room with a private bathroom.

In order to achieve care that is focused on the patient, Dr. Dietz says that effective communication is the best advantage for efficiency. In his hospital, the communication pathway among surgeons, nurses and administration is short. "A physician and a nurse can talk in the morning about a change and it will be made by that afternoon," he says. "There is complete transparency."

By eliminating the bureaucracy, physicians and staff are able to stay focused on patient care. Dr. Dietz suggests that orthopedists should figure out their target customers and then make sure that they take care of them, both inside and outside of the facility. This extends to the community and other possible surgeons who may want to join their staff.

"Surgeons have a personal relationship with their primary customer, the patient, but they must also think about how they relate to hospitals, the community, the malpractice environment and government," Dr. Dietz says. "Hospitals have to be attractive to both the patient and the surgeon while maintaining community service required for tax-exempt status and increasing government oversight. Right now, the competition is to provide the optimum patient experience. We all need each other to make it happen."

10. Healthcare reform may impact physician-owned hospitals
According to Dr. Dietz, the biggest impact proposed healthcare reform may have on orthopedics and surgeons in hospitals is by limiting the amount of control physicians have over patient's experience at the hospital, including cost and quality.

"Physician ownership gives physicians the incentive to be involved in decisions at their hospital," Dr. Dietz says. By having ownership, he notes that physicians are responsible and accountable for what goes on at the facility.

New legislation could prevent the creation of or the growth of new physician-owned facilities, according to Dr. Dietz. "Most physicians are trying to do the right thing when it comes to their physician-owned facilities," he says. "A physician and patient working together are going to make the best decisions for care, but this is hard to dictate through legislation."

Dr. Dietz says that in order for physicians to ensure that their concerns over the restriction of physician ownership are heard, it is important for them to get their message heard by lawmakers. One way is to present the benefits from a patient perspective, he notes. "Patients and physicians working together can keep costs down because it aligns incentives," he says.

Dr. Dietz is an orthopedic spine surgeon with OrthoIndy and on the board of directors of the Indiana Orthopaedic Hospital. Learn more about the Indiana Orthopaedic Hospital.