Tag Archives: Mohs Surgery

A Priori Tumor Grading Scale to Triage and Schedule Post COVID-19 Mohs Surgery Patients

The United States is slowly relaxing stay-at-home orders and reopening businesses to reverse the nation’s ailing economy after the spread of the coronavirus that killed millions of jobs and pummeled the global economy. The virus was initially identified as a cluster of pneumonia cases in Wuhan, Hubei Province of China. Later reclassified as a Novel Coronavirus on December 31, 2019, by the World Health Organization (WHO), and health experts in the US, Canada, Germany, Russia, China, Korea, Japan, and Nigeria declared COVID-19 as a Global Pandemic. During the peak of the COVID pandemic, the Centers for Disease and Prevention, the U.S. Centers for Medicare and Medicaid Services, and professional organizations issued countermeasures to flatten the curve, such as elective surgical procedure cancellation. The coronavirus infections are still on the upswing in Texas, Arizona, Florida, and Utah.

A system to forecast the transmission of the virus based on live and current data is critical (Petropoulos & Makridakis, 2020). Cumulative first wave data aggregated nationally and globally could provide accurate forecasting of probable second wave COVID-19 transmission. While accurate forecasting of the virus’s spread is essential, it is critical to establish guidelines to avoid a Coronavirus rebound and frivolous lawsuits that could stunt economic recovery. In the absence of liability protection that shields medical facilities, and employers, it is critical to developing a scheduling point system that controls the number of patients in the waiting area that could be exposed to the asymptomatic transmission of COVID-19. Even with robust liability protection, negligent facilities could still be punished and be sued for damages. The average wait period is 18 minutes during a medical visit. The patients have enough time to mingle, increasing the probability of transmission of infectious diseases based on the amount and nature of contacts between healthy and infected individuals (Goscé & Johansson, 2018). A priori tumor grading scale in scheduling Mohs patients in the post-COVID period as it relates to the parameters for diffusion is vital for the safety and protection of both the patients and healthcare workers. Depending on the tumor grade, the overall degree of connectivity, comorbidity in association to tumor history using the Labilles “United Paradigm of Cancer Causation” (2017), the patient needs to be seen as the earliest. The grading scale introduced on the “Manual of Frozen Section Processing for Mohs Micrographic Surgery” (2008) is an urgency-scoring system to assist Mohs surgeons, administrators, and staff in triaging surgery patients.

References

Beggs, C. B., Shepherd, S. J., & Kerr, K. G. (2010). Potential for airborne transmission of infection in the waiting areas of healthcare premises: stochastic analysis using a Monte Carlo model. BMC infectious diseases10(1), 247.

Franczyk, B. (2019, July). An Intelligent and Data-Driven Decision Support Solution for the Online Surgery Scheduling Problem. In Enterprise Information Systems: 20th International Conference, ICEIS 2018, Funchal, Madeira, Portugal, March 21-24, 2018, Revised Selected Papers (Vol. 363, p. 82). Springer.

Friedman, E., Friedman, J., Johnson, S., & Landsberg, A. (2020). Transitioning out of the coronavirus lockdown: A framework for zone-based social distancing. arXiv preprint arXiv:2004.08504.

Goscé, L., & Johansson, A. (2018). Analysing the link between public transport use and airborne transmission: mobility and contagion in the London underground. Environmental Health17(1), 84.

Labilles, U. (2017). Pathopoiesis mechanism of smoking and shared genes in pancreatic cancer (Copyright Registration No. TX0008490984) [Ph.D. dissertation, Walden University]. ProQuest Dissertations Publishing.

McCulloch, Hetzer, Geddis, McConnell, Brock, Keating, Labilles, Marino, Beck, Wade & Fisher (2008). Manual of Frozen Section Processing for Mohs Micrographic Surgery. In F. Fish III (Ed.). Labilles, U, Immunohistochemistry (p.1201). American College of Mohs Surgery.

Petropoulos, F., & Makridakis, S. (2020). Forecasting the novel coronavirus COVID-19. PloS one15(3), e0231236.

Bridging the Technology Gap and Geographic Divide

This morning, I attended a webinar on the transitioning to ICD-10 CM and its impact on Public Health Surveillance presented by Peter Hicks of Centers for Disease Control and Prevention (CDC). While its benefits and challenges were discussed, the question to ask is the cost implications of the transition. Another question to ask is its compatibility to existing health information technology. I believe at this point, we need to embrace its advantages, and explore the merging of this initiative on its potential for higher quality and patient-centered care. Setting this topic aside for future dialogue, let me follow-up last week’s discussion on the true, meaningful use of personal health records (PHR), and health information exchange (HIE). In this milieu, let me discuss the promise of telehealth on higher quality and patient-centered care. The geographic separation between regional multi-site healthcare system in which one site is 32 miles or even 51.4 miles away is no longer a logistic problem using telehealth. The quality of care of the traditional model, where health care takes place when the patient and the provider are together at the same time and place can be amplified by current modern system of healthcare. It is important to acknowledge the importance of modern telecommunications and information technologies in providing management flexibility to providers, administrators and managers. It bridges the geographic separation between the patient-provider and management-staff, and allow us to challenge the notion of location and time. Video conferencing can be used to communicate with the provider, where the patient is located one part of the state and the physician is located at another part, or to show new Mohs technicians to perform cryotomy or frozen section immunohistochemistry. In this model, we can remotely monitor patient’s physical condition. Telehealth in concert with disease-specific surveillance data can assess the need for community outreach to educate and inform about the significance of the intervention.

The ability to capture and transmit images using the internet, teleconsultation can be used as an additional approach to teaching new surgical techniques, unbiased by doctrine or surgeon’s experience, enabling accurate quantitative criteria to evaluate the effectiveness of surgical cuts. In the context of cutaneous surgery, whereby contemporary research tools may become one of the criteria in the designing and performing of operations—telemedicine could be an innovative teaching platform presenting systematic pursuit of accurate, optimal cutting patterns and new surgical techniques. This capacity, when used in combination with digital pathology, could offer an alternative method to comply with Clinical Laboratory Improvement Amendments (CLIA) proficiency testing compliance on sharing Mohs slide images with another laboratory to confirm the quality of test of patient frozen section samples. In a multidisciplinary approach, it could bridge the consultation with dermatopathologist on the critical success of a high-quality Mohs surgery program. The dermatopathologist can play a role in quality assurance by reviewing Mohs slides at regular intervals to satisfy the requirement for proficiency testing. Teleconsultation and digital pathology can help assess margins in rare and difficult tumors. Moreover, consultation with dermatopathologist helps in ruling out residual disease or for further immunohistochemistry studies, as well as consultation to assess perineural involvement and uncertain frozen section diagnosis of unusual proliferative lesions. High ground such as remote monitoring of the progress of surgical repairs; we need to acknowledge the challenge in which many of these technologies can impact privacy and security. Telemedicine network structure may have an advantage over competitive hospital- or university-based networks, but the challenge will always be funding and organizational support.

References

Edwards, M. A., & Patel, A. C. (2003). Telemedicine in the state of Maine: A model for growth driven by rural needs. Telemedicine Journal and e-Health9(1), 25-39.

Labilles, U. (2014). Telehealth: Bridging the Geographic Challenge. (Unpublished, PUBH-8270-2. Health Informatics and Surveillance. 2014 Spring Qtr. WK8Disc) Walden University, Minneapolis.

Laureate Education, Inc. (Executive Producer). (2011). Introduction to health informatics and surveillance: Telehealth. Baltimore, MD: Johnson, K. & Speedie S.

Sanders, T. B., Bowens, F. M., Pierce, W., Stasher-Booker, B., Thompson, E. Q., & Jones, W. A. (2012). The Road to ICD-10-CM/PCS Implementation: Forecasting the Transition for Providers, Payers, and Other Healthcare Organizations. Perspectives in health information management/AHIMA, American Health Information Management Association9(winter).

Terry, N. P. (2012). Anticipating Stage Two: Assessing the Development of Meaningful Use and EMR Deployment. Annals Health L.21, 103.

Tilleman, T. R. Optimization of Incisions in Cutaneous Surgery including Mohs’ Micrographic Surgery.