JANUARY / FEBRUARY 2009 | Volume 15 | Number 1
Rise of the Smart Patient Top 10 Risk Management Issues
Evidencebased Medicine: A Term in Search of a Definition
Not only could a disability slow your pace... it might also stop your income. According to the Insurance Information Visit Institute (III, 2007), 43% of individuals Affinity.com/ between the ages of 40 and 65 will www.Marsh nload.html ow suffer from a long-term disability. pages/cmad rmation If you suffer a disabling injury or illness and can’t continue working, do you have a reliable financial source to help replace your income?
for more info ation. c and an appli
Santa Clara County Medical Association members can turn to the SCCMA-sponsored Long Term Disability Insurance Plan. This plan is designed to provide a monthly benefit of up to $10,000 if you become Totally Disabled. Members age 50–59 are eligible to apply for up to $6,000 per month. Learn more about this valuable plan today. Call 800-842-3761 for free information. Or, download information and an application at: www.MarshAffinity.com/pages/cmadownload.html Sponsored by:
Hartford Life and Accident Insurance Company, Simsbury, CT 06089. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (AGP-5719) • #CMA1-903
DBA in CA: Seabury & Smith Insurance Program Management • CA License #0633005 • © 2008 Seabury & Smith Insurance Program Management 777 South Figueroa Street., Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com • 12/08 Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).
A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION
From the Editor’s Desk.................................................................................6 Joseph S. Andresen, MD
A Day at the President’s Inauguration.......................................................7 Joseph S. Andresen, MD It was cold. It was crowded. It was crazy. It was historic. A pilgrimage for so many from so far. More on page 7
“Evidence-based”—A Term in Search of a Definition.............................10 Brian S. Alper, MD, MSPH
Rise of the Smart Patient...........................................................................14 Daniel Friedland, MD
Information for Physicians: Routine HIV Screening................................18 Santa Clara Valley Public Health Department
Ask Your Advocate.....................................................................................19 Sandie Becker, CMC
Best Websites and Local Libraries for Your Patients Who Want More Information.................................................................20
Patient-oriented outcomes are outcomes that affect quality of life without extrapolation. Examples include mortality, incidence of myocardial infarction, and presence and severity of pain.
Candace Ford, MLIS; Aleta Kerrick, MA
The Top 10 Risk Management Issues for California Medical Office Practices........................................................22 Kathleen Stillwell, RN, MPA, HAS
More on page 10
Medical Records: Answers to Your Most Commonly Asked Questions..................................................................24 Don’t Be in Turmoil When Reviewing Your Health Insurance!...............25 A Letter From NORCAL...............................................................................26 Members Spotlight: Seham F. El-Diwany, MD and Huy Nguyen, DO.......28
“Many of my patients have become quite sophisticated on the Internet. But others bring in a stack of pages, two inches thick, and want to use our time to sift through them.” More on page 20
AMA Policy Highlights...............................................................................30 Chris Womack
MEDICO News.............................................................................................32 Member News & Happenings...................................................................35 Classified Ads..............................................................................................36
PAGE 3 | THE BULLETIN | JANUARY / FEBRUARY 2009
The Santa Clara County Medical Association Officers
House Officer Representative
President Howard Sutkin, MD VP-Community Health Cindy Russell, MD VP-External Affairs William Lewis, MD VP-Member Services James G. Hinsdale, MD VP-Professional Conduct Jim Crotty, MD Secretary Thomas M. Dailey, MD Treasurer Martin L. Fishman, MD
Jacob Ballon, MD
Community Hospital of Los Gatos: Judith Dethlefs, MD El Camino Hospital: Michael Curtis, MD Good Samaritan Hospital: Eleanor Martinez, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Saranto, MD Santa Teresa Community Hospital: Efren Rosas, MD Stanford Univ. Medical Center: Peter Cassini, MD Santa Clara Valley Medical Center: Patrick Kearns, MD
AMA Trustee - SCCMA John D. Longwell, MD
SCCMA/CMA Delegation Chair Tanya W. Spirtos, MD
CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (District VII)
Chief Executive Officer
John D. Longwell, MD (Hospital Based Physician)
William C. Parrish, Jr.
A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION
Printed in U.S.A.
Editor Joseph S. Andresen, MD
Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 firstname.lastname@example.org © Copyright 2009 by the Santa Clara County Medical Association.
Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association of products or services advertised.
Y MEDIC UNT A CO
IAT SSOC ION • LA
TA CLARA SAN
IF O R N IA
MEMBERSHIP AS OF JANUARY 29, 2009 Active Members.......2,571 Retired Members........ 872 Students....................... 352 TOTAL MEMBERS...... 3,795
PAGE 4 | THE BULLETIN | JANUARY / FEBRUARY 2009
PAGE 5 | THE BULLETIN | JANUARY / FEBRUARY 2009
FROM THE EDITOR’S DESK
A CELEBRATION Gaining a greater understanding of government. by Joseph Andresen, MD I’m flying at 34,000 feet in a Boeing 767, returning from our nation’s capitol and reflecting for the first time on the past seven days. Our family traveled to Washington, D.C. to witness the inauguration of our 44th president. There were too many events to attend or even count. A luncheon for Planned Parenthood, a health policy committee cocktail party, an Alice Waters charity dinner benefiting D.C. Central Kitchen, among other activities, filled my daily schedule. Visiting the Senate Gallery and witnessing the passage of the first legislation of the new administration, the Lilly Ledbetter Fair Pay Act, gave me a deeper understanding of how our government really works. At the Inaugural Ball, President Obama suddenly appeared with his lovely wife, Michelle. “This celebration is not about me. It’s about all of you. We have so many challenges ahead and I can’t meet them alone. I can only do it with your help,” he addressed the crowd. To put this call for action into a historical context, President John F. Kennedy gave a speech over a half century ago. He described the Chinese symbol for crises and emphasized that it contains both the characters for danger and opportunity. Many see danger in our future. There is the uncertainty of the future role of physicians and loss of autonomy. There is fear of further erosion in income in a profession where a young doctor invests a third of one’s lifetime in education and training before entering the work force.
What is clear is that there is a mandate for change and it is happening quickly. In just the past few days, the Obama Administration appointed Richard Besser as acting director of CDC, succeeding Julie Gerberding, and issued an executive order reversing the global gag rule which restores U.S. funding for international non-governmental organizations that provide information regarding legal abortion services. Just two years after Massachusetts’ universal health care law was passed, 98% of its citizens have affordable health care coverage. We should examine, understand, and seek improvement in this working model,
The Chinese symbol for crises contains both the characters for danger and opportunity. knowing that it will be one alternative in a move toward national health care reform. Our opportunity as physicians and patient care advocates is to stay ahead of this growing momentum. It behooves us to stay directly involved in shaping our future, rather than sitting on the sidelines. We know too well the overwhelming frustration of endless paperwork, authorization hurtles, and problems with reimbursement that interfere with our ability to care for our patients. Only our voice and a seat at the bargaining table will result in health care reform that is effective, comprehensive, and in the best interests of
Joseph Andresen, MD is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara valley area. our patients and our nation. Your active participation in the SCCMA, CMA, and other physician organizations will ensure that this happens. This month’s SCCMA Bulletin includes articles which discuss the myriad of Internet and advertising information available to our patients. How can we assist them in obtaining accurate and relevant resources to stay well informed? What is evidence-based medicine? Read Dr. Brian Alper’s seven steps to understanding what truly qualifies for EBM. How can we point the “smart patient” in the right direction? Dr. Daniel Friedland provides useful information that we use to enlist our patients in becoming more effective critical thinkers and well informed in the process. Do you know who has legal rights to access medical records? What are allowable copying charges? How long should medical records be retained? You’ll find all the answers to these questions within. Patient termination, test result follow-up, missed appointments, and dealing with a disruptive patient are just a few of the top 10 risk management issues for office-based practices. Learn how to avoid these potential pitfalls.
PAGE 6 | THE BULLETIN | JANUARY / FEBRUARY 2009
A day at the president’s inauguration January 20, 2009 | Washington, DC by Joseph Andresen, MD
It was cold. It was crowded. It was crazy. It was historic. A pilgrimage for so many from so far. A Woodstock of our times for others. People greeted each other with a jubilance that I’ve never experienced before. “It was a great day and I’d do it all over again despite the cold and the crowds’, said an elderly woman as we both drank hot apple cider to take away some of the chill in our bones.
Waiting for the Metro before dawn: Cold!
The lines were long but enthusiasm was high!
Crowd control was lacking outside the security gates.
Even as people waited in tunnels for hours under the Mall.
The reward was getting inside to get a glimpse of our Nation’s Capitol with anticipation of what was to come.
PAGE 7 | THE BULLETIN | JANUARY / FEBRUARY 2009
January 20, 2009, continued from previous page
Where the crowd hung on every spoken word in the moment.
Surrounded by a sea of faces....
Some waved flags.
Even with the enormity of the crowd and the space, there was an intimacy of images.
I found comfort and solace with the many families that shared this time together.
Many waved goodbye to Marine One as it hovered overhead with President Bush who looked at the White House one last time.
PAGE 8 | THE BULLETIN | JANUARY / FEBRUARY 2009
Partners in Excellence Our specialized interdisciplinary team of medical directors, nurses, social workers, chaplains, and community grief counselors are trained to assist you in the management of your patients needs. • Our physicians are experts in palliative and end-of-life care • We guide individuals and families in setting and meeting their goals in this new phase of life and focus on the patient’s and family’s physical and medical needs as well as their emotional and spiritual well-being
• Our Community Grief Support Center offers age-specific and loss specific support groups including anticipatory grief for children, teens and adults • Since 1979, our legacy of community education, advocacy and outreach has set the standard for quality hospice care state-wide and nationally
• Transitions provides pre-hospice clients with volunteer support and assistance in navigating life-limiting illness and connection to community resources
Hospice of the Valley…doing hospice in the way it was meant to be done. — California State Surveyors
408.559.5600 l hospicevalley.org
PAGE 9 | THE BULLETIN | JANUARY / FEBRUARY 2009
“Evidence-based MEDICINE” A Term in Search of a Definition By Brian S. Alper, MD, MSPH Evidence-based is a term that is as misused and misidentified as are politicians’ quotes. The term has been used to denote systematic evaluation of research, but has also been used to confuse and “sell” concepts without providing comprehensive evaluation of the evidence supporting the concepts. When clinical reference content is accurately and consistently derived from the best available research using transparent methodology, then the “evidence-based” approach allows clinicians to make informed decisions that enable them to provide the best care to their patients at the point-of-care. Evidence-based, in any field, means that conclusions are based on the best available evidence. This doesn’t mean that the evidence will never change or be altered; to be consistently reliable, evidence must be continuously and consistently and systematically identified, evaluated, and selected. For evidence-based medicine (EBM) content to correctly, accurately, and reliably be labeled as evidence-based, the following steps are required: 1. Systematically identifying all applicable evidence 2. Systematically selecting the best available evidence from that identified 3. Systematically evaluating the selected evidence (critical appraisal) 4. Objectively reporting the relevant findings and quality of the evidence 5. Synthesizing multiple evidence reports
6. Deriving overall conclusions and recommendations from the evidence synthesis 7. Changing the conclusions when new evidence alters the best available evidence Editors use these seven steps to consider medical literature for inclusion in DynaMed, an online clinical EBM resource for clinicians at the point-of care. But simply stating that seven steps are needed isn’t enough to be assured that the best available evidence is being presented.
Patient-oriented outcomes are outcomes that affect quality of life without extrapolation. Examples include mortality, incidence of myocardial infarction, and presence and severity of pain.
Each step needs definition, clarification, and process. Outlining the editors’ process through these steps will help illustrate what is required behind the scenes for clinicians to practice EBM.
is conducted using more than 500 journals directly or indirectly through many journal review services and other sources of systematic evidence evaluation. For each source monitored, each issue is reviewed cover-to-cover. All entries are considered, because information in letters to the editor, editorials, and “reporting from the literature” pages may contain reports of new research that would be otherwise unidentified if relying exclusively on abstracts posted with traditional research articles. When adding a new topic or critically revising an existing topic, PubMed Clinical Queries is used to providing systematic searches for identification of the best available evidence. In addition, numerous sources are searched for evidence-based reviews (such as Cochrane Database of Systematic Reviews), for guidelines (such as National Guideline Clearinghouse), and for traditional reviews. Editors then move to the second step in the process. Each article is assessed for clinical relevance and each relevant article is further assessed for validity relative to existing content. The most valid articles are summarized, the summaries are integrated with content, and overview statements and outline structure are updated based on the overall evidence synthesis.
To systematically identify all applicable evidence in Step 1, an extensive set of current literature is monitored daily. Systematic Literature Surveillance (SLS)
PAGE 10 | THE BULLETIN | JANUARY / FEBRUARY 2009
Determining clinical relevance is the first consideration in systematically selecting the best available evidence from that identified. The relevance of medical information is different for every user. DynaMed is used in clinical care by practitioners with a wide range of experience and interests, and is also used in medical education. When adding information, the editors consider several questions to determine relevance. Does this information have a direct bearing on patient-oriented outcomes? Patient-oriented outcomes are outcomes that affect quality of life without extrapolation. Examples include mortality, incidence of myocardial infarction, and presence and severity of pain. These are also called clinical outcomes. Diseaseoriented outcomes are used as surrogate markers for monitoring the effects of interventions ultimately intended to affect patient-oriented outcomes. Examples include cholesterol concentration, blood pressure, and bone mineral density. Patients are only interested in these outcomes as a means for affecting clinically significant outcomes such as mortality or fracture incidence. Because DynaMed is primarily a clinical tool for use during patient care, patientoriented outcomes information is considered relevant and included. Patient-oriented evidence is given priority over disease-oriented evidence, with disease-oriented evidence entered only if it adds substantially new information. In the absence of patientoriented evidence, might this information be useful in clinical decision-making? Much of medical
knowledge is still lacking in terms of patient-oriented outcomes research. Clinical decisions based on extrapolated disease-oriented evidence are not proven to be appropriate. However, clinicians still need to make decisions in situations where patient-oriented evidence is not yet available. Disease-oriented evidence is considered relevant for inclusion in situations where patient-oriented evidence is lacking. Individual clinicians will have to determine if this information is considered relevant within their practice. When disease-oriented evidence is not presented as such in the supporting reference, commentary will be added and may appear as “patient-oriented outcomes not assessed,” “clinical outcomes not assessed,” or specific commentary pointing out problems with
extrapolating the information to clinical care. Is this information part of a clinical controversy? In situations where the evidence does not clearly support or refute a clinical fact, opposing views are presented. DynaMed is not designed to resolve clinical controversies and strives to present information with as little “inappropriate” bias as possible. The inherent bias towards patient-oriented outcomes is considered appropriate. Information that questions “standard” approaches and has a potential bearing on patient-oriented outcomes is considered relevant for inclusion. Is this information that is of unique interest due to popularity? Some medical information is not clinically relevant, but widely publicized. Summarization of this type of information (often with commentary) is relevant to users if it is likely that clinicians will be asked about it during clinical encounters. It is important for physician and patient education to point out where this type of information is not clinically applicable. Clinically relevant articles must be assessed to determine the scientific validity of conclusions and facts presented before consideration for use. Conducting critical appraisal for all articles would be wasteful if these articles would not make a change to the existing knowledge base. Easily identifiable study features (e.g. study method, sample size) are compared with existing studies in current content to determine if new articles potentially represent the best available
PAGE 11 | THE BULLETIN | JANUARY / FEBRUARY 2009
Evidence-based Medicine, continued from previous page evidence. Articles that do not provide relevant information with validity that meets or exceeds the existing content are excluded at this stage. In Step 3, editors have found that abstracts in research publications often do not accurately reflect the methodologic quality and results found in fulltext articles. Article summaries in other publications also often do not accurately reflect the methodologic quality and results found in full-text articles. Full-text evaluation of articles is required for: •
Any article rated as Level 1 [likely reliable] evidence or Grade A recommendation [consistent highquality evidence]1 Any article potentially ratable as Level 1 or Grade A based on abstract-only information; full-text evaluation is necessary to provide lower levels or grades Any article for which definition of absolute magnitude of effect and/or detailed description of interventions or exposures are necessary, regardless of level of evidence Any article which represents the most important guidance for a topic, regardless of level of evidence
Reports used for updating content represent the best available evidence for the specific content under consideration. Evidence may be labeled in one of three levels – Level 1 (likely reliable) Evidence; Level 2 (mid-level) Evidence; Level 3 (lacking direct) Evidence.1 Articles that potentially warrant the highest evidence ratings undergo complete critical appraisal using methods established in the Users’ Guides to Evidence-Based Practice from
the Evidence-Based Medicine Working Group.2 If serious methodological shortcomings are discovered (sufficient to affect clinically relevant results), then the evidence is labeled as mid-level evidence and the shortcomings are described.
Visit DynaMed Online DynaMed, a leading point-of-care clinical reference tool, is available to all health care professionals at www.ebscohost.com/ dynamed. Subscribers to the site
When reporting the evidence, editors consider all of the following as they go through Step 4:
are provided with the most up-to-
Were all relevant outcomes reported in the original article?
medical journals and evidence review
What are the most relevant outcomes to report in the topic?
For relevant outcomes, what is the magnitude of effect? This may be represented by absolute rates and number needed to treat (NNT) or harm (NNH) abbreviations, or by absolute differences in continuous variables (e.g. mean decrease in 1.3 points on 0-10 visual analog pain scale).
website is thoroughly reviewed for
Were the findings clinically significant?
to subscribe to this site.
In the case of no statistically significant differences, were the findings robust enough to rule out clinically significant difference?
Are there any methodologic limitations sufficient to alter reliability of clinical conclusions?
In Step 5, evidence-based summarization of articles is necessary, but insufficient for a point-of-care reference. Evaluating individual evidence reports requires synthesizing multiple evidence reports. Addition, deletion, and organization of information within content is done with consideration of levels of evidence. When multiple articles are present on the same topic, preference for
date, evidence-based information gathered from more than 500 databases that will assist them in making the best clinical decisions when it is needed most. Updated daily, the data presented on DynaMed’s scientific relevance and validity, and then integrated with existing content to produce the best available evidence on various health-related topics. Residents, medical students, practicing physicians, and medical scholars looking for answers to complex clinical questions are invited
inclusion and organization is based on the quality of methodology, e.g. preference given to data derived from randomized controlled trials over data from prospective observational studies, which is given preference over retrospective studies, which is given preference over anecdotal reports. When data of lesser quality does not add any substantially new or different information, this data is then deleted from content. Moving to Step 6, deriving overall conclusions and recommendations from the evidence synthesis is required for a comprehensive point-of-care reference.
PAGE 12 | THE BULLETIN | JANUARY / FEBRUARY 2009
Multiple evidence reports of similar quality are organized such that the overall conclusions quickly provide a synthesis of the best available evidence.
Evidence-based Medicine Research Websites
In DynaMed, Treatment Overviews (the ultimate synthesis of evidence for a clinical topic) are based upon all of the available evidence in the treatment section, and selection of the most important concepts. As new topics are created and existing topics are critically revised, Treatment Overviews are explicitly linked directly to the supporting evidence synthesis. The final step in DynaMed’s evidence-based methodology is changing conclusions when new evidence alters the best available evidence. This step is crucial because new evidence is published every day. Having new evidence summaries handled separately from reviewed content, in a manner requiring the clinician to search in two locations to synthesize the entire story, would make finding the best available evidence more difficult. As soon as new evidence is evaluated using the six steps governing systematic processing, it is added to the appropriate topic(s) in context. This process allows immediate and comprehensive access to the best available evidence as it occurs. In conclusion, while it is true that the definition of “evidence-based” can be confusing and is often misused, when the term is correctly used, and the evidence in an EBM content source is accurately and consistently derived from the best available evidence, clinicians can use that content source to make decisions that enable them to provide the best care to their patients at the point-of-care. ABOUT THE AUTHOR: Dr. Alper is the founder and manager of DynaMed, a point-of-care reference resource designed to provide doctors and medical researchers with the best available evidence to support clinical decision-making.
• Centre for Evidence-based Medicine http://www.cebm.net • Super Smart Health http://www.supersmarthealth.com • Netting the Evidence http://www.shef.ac.uk/scharr/ir/netting • DynaMed http://www.ebscohost.com/dynamed • Duke University Medical Center Library http://www.mclibrary.duke.edu/subject/ebm • Evidence-based Medicine Resource Center http://www.ebmny.org • University of Maryland Health Sciences & Human Services Library http://www.hshsl.umaryland.edu/resources/ evidence.html • emedicine from WebMD http://www.emedicine.com • SUNY Downstate Medical Center
Reprinted with permission of San Diego Physician, the official publication of the San Diego County Medical Society.
http://library.downstate.edu/resources/ebm.htm • The Society for Clinical Trials
Resources: 1. Definitions and sources available at www.ebscohost.com/ dynamed/levels.php. 2. Available from the Centre for Health Evidence at www.cche. net/usersguides/main.asp.
http://www.sctweb.org • The James Lind Library http://www.jameslindlibrary.org • PubMed http://www.ncbi.nlm.nih.gov/PubMed
PAGE 13 | THE BULLETIN | JANUARY / FEBRUARY 2009
Rise of the Smart Patient At the Crossroads of Evidence-Based Medicine and Consumer-Directed Health Care By Daniel Friedland, MD
Introduction: The Rise of the Smart Patient How often does this happen in your practice: You enter the room to meet your patient, who presents you with a stack of literature she has downloaded off the Internet, self-diagnosing her perceived medical condition? You walk into the next room and a patient states that he wants a prescription for a new drug after reading information contained on that drug’s website, which he saw advertised on TV. Like it or not, patients are searching the Internet to find health care information. At latest count, over 113 million individuals in the United States have searched for health care information online. They are finding answers to almost any health concern, creating personal health records, finding doctors, hospitals and clinical trials, and managing insurance-related concerns. We are witnessing the Rise of the Smart Patient, driven by the availability of 24/7 health information, reduced time for office visits, rising premiums, and the emergence of high-deductible health plans, all of which press patients to find their own answers to maintain both physical and financial health. With over two million articles published in the literature each year and the emergence of thousands of healthrelated websites, we are also in the midst of an unprecedented information explosion, which can make it very challenging for the patient to find reliable information. And
while being more informed is good, if the information is neither relevant nor reliable, then it’s distracting, time consuming, and potentially frustrating to both the physician and the patient. So the issue is, how can we, as physicians, help guide our patients at the crossroads of information overload and economic concerns to find more reliable information online. For over 10 years, physicians have been using evidence-based medicine (EBM) to sort through the overwhelming amount of information. However, due to time constraints, this is often challenging
Like it or not, patients are searching the Internet to find health care information.
our patients with the most basic principles of EBM and offer appropriate evidencebased resources, it will likely result in their bringing higher quality information to the visit, open new lines of communication, and strengthen a shared decision-making bond that may even save time in the patient encounter. The Evidence-Based Medicine Resource Center at SuperSmartHealth. com provides a free resource that teaches patients the basics of EBM and also provides links to many of the resources mentioned below. EBM teaches patients to think about their health decision-making as a four step process that supports them to: 1. Frame their questions properly; 2. Find the best evidence to answer their questions; 3. Evaluate what they find to ensure it’s relevant and reliable; and
to do in daily practice. On the other hand, many patients have the time, interest, and willingness to perform research online, but they don’t have a systematic way of doing this. This article presents an EBM-aligned strategy to empower physicians to take an active role in enabling these patients to make wise use of online resources to support their quest to become smarter and healthier patients.
Harnessing EBM to Support the Rise of the Smart Patient Most clinicians do not have the time to educate patients on the intricacies of EBM. But, if we can identify and invest
4. Apply the evidence to the particulars around their care.
Step 1: Framing the Question The problem with much of the information patients bring to providers is that it does not answer the right question from the beginning. For example, let’s return to the patient with Internet research supporting his request for the drug he saw advertised on TV. While the patient might initially believe he is the perfect candidate for the medication, re-framing the question using the EBM PICO model (Patient, Intervention, Comparison intervention, Outcome) helps to clarify crucial gaps in
PAGE 14 | THE BULLETIN | JANUARY / FEBRUARY 2009
the information required to make a fully informed decision. Introducing and using the PICO format with such a patient invites a discussion about whether the patient population (P) in the study is indeed similar to the patient; the intervention (I) is available on his health plan; the benefit of this particular therapy was found not only more effective than placebo, but also more effective when compared (C) against the current best available regimen; and that the outcomes (O) of benefit demonstrated in the research are truly meaningful to the patient’s quality and length of life, rather then simply a change in some laboratory test value. This format saves everyone time by streamlining the discussion and increasing the likelihood patients will find the right answers to the right questions when they proceed to search for information on the Internet.
Step 2: Finding the Evidence When it comes to guiding our patients to help them find better information on the Internet, it’s important to recognize where they are searching and to direct them to high quality resources that may be underappreciated. According to the Pew Online Health Search Survey (2006), 66% of individuals begin their health inquiry at a search engine like google.com. This returns an overwhelming amount of information, although Google now enables one to refine the search by categories such as treatment, test/diagnosis, symptoms, causes/risk factors, and alternative medicine. Another
27% start at a healthrelated website. The top trafficked websites, according to Compete. com, are listed in the table below. The quality of these health-related websites has improved dramatically over the years. It is worth surfing these top 10 sites to explore some of the information they provide. Rank Website Visitors/month* (millions) 1 WebMD.com 15.1 2 NIH.gov 8.2 3 RevolutionHealth.com 6.1 4 RightHealth.com 5.6 5 everydayHealth.com 5.0 6 MayoClinic.com 5.0 7 MedicineNet.com 4.2 8 RealAge.com 3.0 9 Drugs.com 2.8 10 Healthline.com 2.4 * January 2008
Of the top commercial websites, WebMD.com and RevolutionHealth. com include comprehensive coverage of health conditions, drugs, assessment of symptoms, screening, risk assessment tools, discussion boards with physicians and fellow patients, personal
PAGE 15 | THE BULLETIN | JANUARY / FEBRUARY 2009
Rise of the Smart Patient, continued from previous page health records, and directories for health care providers and hospitals. The top nonprofit health site, NIH.gov, the medical research agency for the United States, acts as a clearinghouse for the 27 institutes and centers that make up the NIH. It provides access for consumers to high quality information on a comprehensive A-Z list of health topics, as well as newsletters, and a helpful list of tollfree hotlines to health organizations across the country. Beyond the websites ranked most popular are other quality resources too numerous to mention in the space of this article. However, you can find links to many of them through The Consumer and Patient Health Information Section (CAPHIS) of the Medical Library Association’s “Top 100 List” of “Health Websites You Can Trust” at http://caphis. mlanet.org/consumer/generalhealth.html. One resource worth mentioning is the first referenced on the CAPHIS list: MedlinePlus.gov from the National Library of Medicine. Drawing approximately 200,000 visitors per month (according to Compete.com in January 2008), it is relatively underappreciated when compared with the most trafficked websites above. MedlinePlus is one of the best patient education resources you will find, with extensive information on 750 healthrelated topics, the latest health news, a comprehensive resource on drugs and complementary alternative medicine supplements, an illustrated medical encyclopedia, interactive patient tutorials, a medical dictionary, and physician and hospital directories. One of their most useful resources is an extensive list of organizations by health topic (http://www. nlm.nih.gov/medlineplus/organizations/ orgbytopic_a.html) which has been
pre-screened for quality, authority, and accuracy of health content, thus enabling the patient to efficiently identify the top few websites related to their particular health condition. A few other resources referenced by CAPHIS also bear mention: Healthfinder.gov, developed by the Department of Health and Human Services; MayoClinic.com (one of the top 10 most popular sites and contributes information to Revolution Health); the ClevelandClinic.org/health/ (which contributes information to WebMD); and FamilyDoctor.org, produced by the American Academy of Family Physicians. The strong point of many of the resources listed above is that they cater to the health literacy of the average Internet user. For select patients with high health literacy (or for their designated “EBM champions” who search on their behalf), the following 3-step drill down strategy may also be offered as an efficient and rigorous way to find high quality evidencebased information. First, these patients may begin searching the same online medical textbooks health care providers search, such as those at Emedicine.com and UpToDate.com. Many chapters of both resources provide links to free consumer information. The health professional information of UpToDate requires a subscription, but motivated patients may pay $20/week or $45/month for full access. Next, patients can drill down further looking for high quality evidencebased information on focused clinical questions in the form of systematic reviews or practice guidelines. The Cochrane Collaboration (http://www3.interscience. wiley.com/cgi-bin/mrwhome/106568753/ HOME), publishes some of the highest
quality reviews around and provides free abstracts with easy to read plain language summaries for patients. The National Guidelines Clearinghouse (NGC) (guidelines.gov) is the single best resource to find practice guidelines from hundreds of institutions and affiliated organizations. Links are provided to the major recommendations and, where available, to the full-text of each guideline and handouts for patients. Finally, patients who want to drill down even further to search for the latest studies on their specific questions of interest can search the U.S. National Library of Medicine’s MEDLINE database at PubMed.gov. PubMed currently searches over 17 million records from over 4,800 journals. A helpful tutorial is available to guide individuals in using its powerful search tools, including the “Clinical Queries” link that has filters for searching on questions of therapy, diagnosis, etiology, and prognosis. Abstracts can be downloaded for most articles and some have links to free full text articles. For those that don’t, one can try retrieving the full text article through freemedicaljournals.com, which provides free access to over 430 journals.
Step 3: Evaluating the Evidence According to the Pew survey, almost three quarters of health seekers do not consistently check the sources and date of the health information they find online. In partnering with patients to improve health care, it’s essential to highlight the importance of evaluating the reliability of online information. There are two key steps to evaluating information online: first, evaluate the reliability of the website searched and second, evaluate the quality
PAGE 16 | THE BULLETIN | JANUARY / FEBRUARY 2009
of the research that the website ideally references. MedlinePlus has a great section on “Evaluating Health Information Online” at http://www.nlm.nih.gov/ medlineplus/evaluatinghealthinformation. html. It leads off with a flash tutorial at http://www.nlm.nih.gov/medlineplus/ webeval/webeval.html which goes through four key considerations, including who authored and funded the site, how to determine quality, and issues of privacy. The big issue for patients evaluating the quality of research referenced on websites involves them recognizing a hierarchy of evidence: how randomized controlled trials (and systematic reviews to which they contribute) provide more reliable information than observational studies, which provides superior information to anecdotal evidence. Health care providers and patients can find more information on this and on how to tell whether evidence is relevant, believable, and meaningful at the EBM Resource Center at SuperSmartHealth.com.
Step 4: Applying the Evidence Once patients identify more reliable information, they will be more prepared to engage in the final step, discussing how the evidence applies to them and share in the decision-making process. This step involves a consideration of the best options, extrapolating from the evidence the likelihood of the key outcomes for each option and weighing the patients’ preferences for those outcomes. In deciding whether one approach is a step better than another, physicians can outline several factors the patient may consider by using the pneumonic STEPC
(Safety, Tolerability, Efficacy, Price, and Convenience). This pneumonic may help the patient remember the key outcomes to be weighed and frame subsequent discussions with health care providers. In addition, great resources are available to help prepare patients, in advance, for decision-making discussions with their providers. The Foundation for Informed Medical Decision Making (informedmedicaldecisions.org) and its partner Health Dialog (healthdialog.com) work with health plans and employers to provide shared decision programs that help patients clarify their options and the risks, benefits, and preferences associated with each. The Ottawa Health Research Institute (http://decisionaid.ohri. ca/index.html) provides one of the best free resources for patient decision aids. In addition to providing generic forms to help patients structure their decisions, they provide an extensive A-Z list of diseasespecific decision aids, all of which have been graded according to the International Patient Decision Aid Standards to ensure they incorporate valid information. As patients become more informed about their options and empowered to make decisions, we also need to be mindful of the context in which decisions are made. Optimal health is more than treating disease. Any decision may also be influenced by patients’ socioeconomic circumstances, cultural context, spiritual values, and their personal vision and goals for optimal health and well-being.
find evidence in more reliable databases, and become more critical in the way they evaluate information, patients will bring more reliable evidence to their office visits. If they also have the ability to recognize the factors that contribute to the decisionmaking process, they will come to the visit well-prepared to discuss their various options. It’s a vision to the future—a partnership between physician and patient, leveraging the skill set and time of both parties, that may not only save time, but result in more fulfilling encounters and smarter, healthier, and more satisfied patients. About the Author: Daniel Friedland, MD is the author of Evidence-Based Medicine: A Framework for Clinical Practice and founder of SuperSmartHealth.com, which incorporates the principles of EBM into a vision of optimal health and well-being. For the past 10 years, Dr. Friedland has trained thousands of physicians and allied healthrelated professionals in EBM across the United States. Dr. Friedland now also provides EBM programs for patients to facilitate their partnership with health care providers to better health. Reprinted with permission of San Diego Physician, the official publication of the San Diego County Medical Society.
CONCLUSION By working with our patients, we can play an active role in supporting the Rise of the Smart Patient. In teaching patients EBM-aligned strategies which enable them to frame questions properly,
PAGE 17 | THE BULLETIN | JANUARY / FEBRUARY 2009
INFORMATION FOR PHYSICIANS
Routine hiv screening While significant advances have been made over the last two decades, HIV remains an epidemic affecting an estimated 4,158 people living in Santa Clara County. The Public Health Department is committed to reducing barriers to early diagnosis of HIV infection and increasing access to quality medical care, treatment, and ongoing prevention services for those with a diagnosis of HIV infection. One of the key strategies in responding to the ongoing HIV epidemic is making HIV testing a routine part of medical care. •
The Centers for Disease Control and Prevention estimate that one-fourth of the people living with HIV do not know they are infected. That’s approximately 515 in Santa Clara County who could be spreading HIV to their partners unknowingly.
1894), requires that health care plans and health insurers provide coverage for HIV testing, regardless whether the testing is related to a primary diagnosis. Written consent for HIV testing is no longer required. Assembly Bill 682, signed by the Governor in 2007, allows for patients to be tested for HIV without written consent. Patients may be tested for HIV, unless they specifically opt out of testing. The Public Health Department is here to help. •
Together, we can reduce the spread of HIV, and improve the lives of those living with HIV and AIDS.
Anonymous testing and risk reduction counseling – The Public Health Department provides free confidential and anonymous HIV testing at the Crane Center and its mobile sites, as well as by Alternate Test Site locations throughout the County. Public Health and Alternate Test Site locations can be found at www.SCCCraneCenter. org. Additional testing locations can also be found at www.HIVTest.org.
Partner Counseling and Referral Services (PCRS) – Through PCRS, persons, many of whom may be unaware of their risk, are informed of their exposure or possible exposure to HIV. Notified partners can choose whether to be tested and can receive counseling about practicing safer behaviors to avoid future exposure to HIV. If they are found to be infected, they can seek early medical treatment and practice behaviors that help
People living with HIV can receive effective treatment, resulting in improved health and extended life, if their HIV infection is diagnosed earlier.
The American College of Physicians releases new HIV testing guidelines. New ACP guidelines, which appear in the January 2009 issue of the Annals of Internal Medicine, recommend that clinicians adopt routine screening for HIV and encourage patients to be tested, and that clinicians determine the need for repeat testing on an individual basis. California law requires HIV testing be covered by health care plans/insurers. A new California law, which took effect January 1, 2009 (Assembly Bill
prevent transmission of HIV to others. To obtain materials to assist your HIV-infected patient self-notify their partners, to schedule a dual notification where a trained Public Health HIV counselor facilitates the partner notification, or to request an anonymous notification by the Public Health Department, please contact the Crane Center at 408/792-3720 or CraneCenter@hhs.sccgov.org. •
PAGE 18 | THE BULLETIN | JANUARY / FEBRUARY 2009
Information and resources – The Public Health Department can provide you with a variety of resources and referrals to help you integrate routine HIV testing into your practice. For additional information or to obtain resource materials, please contact the HIV/AIDS Prevention and Control Program at HAP@hhs. sccgov.org or 408/792-5030. Expert clinical consultation on HIV testing, antiretroviral treatment options, drug interactions and toxicity, resistance testing, prophylaxis and management of opportunistic infection, and primary care of persons with HIV/ AIDS is also available through the National HIV/AIDS Clinicians Consultation Center at 1-800/9333413.
CODING & REIMBURSEMENT NEWS
ASK YOUR ADVOCATE Your Physician Advocate Has the Answers! was unrelated to the patient’s terminal condition and are not the designated attending physician, you should append the modifier GW (condition not related to the patient’s terminal condition) to the service code provided.
by Sandie Becker, CMC SCCMA Coding/Reimbursement Specialist Q: How should I code a Mini-Mental exam performed as part of an office visit with a patient who is having memory problems? The physician administration, interpretation, and written report associated with the MMSE (Mini-Mental Status Exam) is included in the Evaluation and Management (E/M) code for the patient encounter and cannot be billed separately.
Q: Medicare, stating that the patient is enrolled in hospice, denied my claim for a patient. How do I get paid? Where the service is considered a hospice service (i.e., a service related to the hospice patient’s terminal illness that was furnished by someone other than the designated “attending physician” [or a physician substituting for the attending physician]), the physician or other provider must look to the hospice for payment. If, as I suspect, you provided a service that
Would you like to receive updated coding & reimbursement news by email? If so, please call the SCCMA office to provide your email address at: 408/998-8850 ext. 3007 or email: sandie@sccma. org. You may also visit our website at: www.sccma.org.
The first rule in contracting for services is that everything is negotiable. You can and should negotiate for your services. Q: I recently discovered that the reimbursement we receive, through a couple of payers with whom our office contracts, is lower than Medicare rates. I want to renegotiate our contracts and I am unsure how to do it. Do you have any suggestions?
The first rule in contracting for services is that everything is negotiable. You can and should negotiate for your services. Good for you for catching this. The second rule is, if a payer offers a fee schedule that is less than what it costs for you to see that patient, ask yourself if you are better off without that payer. Keep those two things in mind when renegotiating. The CMA has a toolkit called “Taking Charge: Steps to Evaluating Relationships and Preparing for
For coding questions and reimbursement issues, contact Sandie at 408/9988850 ext 3007 or email sandie@ sccma.org.
Negotiations.” The toolkit offers tips and step-by-step instructions from understanding your contracts, reviewing and preparing to negotiate with a payer, to monitoring payer compliance after signing a contract. The toolkit also provides checklists and sample practice analysis tools to help you determine your practice’s strengths and weaknesses, as well as the payer’s, before starting negotiations. Members can download the toolkit free from the bookstore on the CMA’s website at www.cmanet.org.
Q: A teenager comes in with a bleeding nose. The pediatrician applies a nitrogen stick to the site. Should an office visit code be billed for the bleeding control? Because the pediatrician used cauterization to control the bleeding, report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), which pays more than all the established office visits except 99215. But if the physician used only pressure to control the nosebleed, and no kind of cauterization, you would code only the appropriate level office visit.
PAGE 19 | THE BULLETIN | JANUARY / FEBRUARY 2009
Best Websites and Local Libraries for Your Patients Who Want More Information By Candace Ford, MLIS, Executive Director, PlaneTree Health Library; Aleta Kerrick, MA, Editor, PlaneTree Health Library “Many of my patients have become quite sophisticated on the Internet. But others bring in a stack of pages, two inches thick, and want to use our time to sift through them.” Sound familiar? The Internet has certainly changed—and sometimes challenged—the patient-professional relationship. With the wild spread of health-related sites over the past few years, the amount of information (and misinformation) that patients are finding on their own is both a blessing and a curse. The best website for patients of any educational level or language is the robust, non-commercial, and well-organized MedlinePlus (www. medlineplus.gov). Maintained by the National Library of Medicine (NLM), a division of the National Institutes of Health (NIH), one appealing facet of MedlinePlus is its straightforward home
page. Even online novices can navigate to the carefully selected information easily. Your patients will also appreciate the site’s lack of clutter, with no advertisements or commercial links. This is welcome relief from health websites that blink colorful advertisements and “sponsored” sections – which rightfully provoke concerns about editorial bias. The name “MedlinePlus” has been confusing to some health care professionals who remember searching “Medline” while in school. In 1997, members of Congress pressed NLM to create a public website for searching and accessing Medline. Dubbed “PubMed,” the site was extremely popular with laypersons. However, the search interface and the abstracts themselves were often too technical for consumers. The general public was clearly hungry for medical information, and just as clearly, they needed a site with consumer-level information that was simpler to search. To fill this void, the NLM debuted MedlinePlus which has grown enormously since its debut 10 years
ago. There are 775 topics in English, extensive resources in Spanish, and some information in 40 other languages. Other sections include information about drugs and supplements, clinical trials, and medical news. There is also a collection of “easy to read” articles, as well as interactive tutorials and videos. The site deservedly has over 10 million visitors each month. NIH also produces a great magazine for your waiting room. Free copies of NIH MedlinePlus Magazine can be ordered by calling 336/547-8970 x3327 or at www.vitalitycommunications.com/ medlineplus/subscription.php. Published quarterly, it is ad-free and features health articles to appeal to a wide patient audience. Physicians may also request free pens, pads, and posters promoting the MedlinePlus website at www. informationrx.org/Splash.html. Meanwhile, the technical PubMed has become ever more comprehensive and immediate access to articles has increased significantly. Full-text availability will continue to
PAGE 20 | THE BULLETIN | JANUARY / FEBRUARY 2009
grow, especially as a recent change in NIH policy mandates that all published results of research funded by the NIH must become available to the public via PubMed. Get to know the new improved Medline and much more at www.pubmed. gov. Another favorite of physicians who want to direct patients to an advertising-free site is UpToDate for Patients (www.uptodate.com/patients). While the professional portion of the site is subscription-only, UpToDate makes its patient section available at no charge. SCCMA member David Stein, MD refers patients to the UpToDate patient section, and notes, “I’m looking forward to investigating MedlinePlus for my patients as well. In my experience, if a source or a site is recommended by medical librarians, it’s worth checking out!” A wide variety of other worthwhile health links for consumers, selected by PlaneTree librarians, can be found at www. planetreesanjose.org/healthlinks.html. One of the most extensive consumer health libraries in the country,
PlaneTree is celebrating 20 years of community service in Santa Clara County. You may recall the original PlaneTree Resource Center, housed in a renovated Victorian across the street from San Jose Medical Center. It is now located on the Mission Oaks campus in space donated by Good Samaritan Hospital. The resource center at El Camino Hospital became a PlaneTree library affiliate in 2004. There are, in fact, many libraries throughout Santa Clara County with expert staff to help people access current health books and medical texts, in-depth databases, and online sources. A list of Bay area public and medical libraries which serve the public is available at www. planetreesanjose.org/otherlibraries.html. As a Santa Clara County physician, you have many ways to help your patients learn more about their conditions. As they become better informed, patients often become more compliant, and may also explore healthier lifestyles, becoming a more effective partner with you in their own health care. Take advantage of the local libraries which
offer your patients professional assistance, and of librarian-recommended online health information sources. Your patients will thank you. About the Author: Candace Ford, MLIS, has directed the PlaneTree library since its inception in 1987. She is a resource specialist for the national PlaneTree organization, which has over 120 hospital and library members across the U.S. Ms. Ford co-authored a chapter in the just-published, second edition of Putting Patients First: Best Practices in Patient-Centered Care. Aleta Kerrick, MA, works part-time as library assistant and editor. Kerrick produces the online newsletter “PlaneTalk,” including the popular column “News You Can Use.” To join their private email list, click “Subscribe” on their homepage, www.planetreesanjose.org. PlaneTree is located at 15891 Los Gatos-Almaden Road (at National Ave.), Los Gatos 95032, 408/358-5667. Free and open to the public on Tues. & Thurs. 2-8pm; Wed., Fri., Sat. 11am-5pm.
PAGE 21 | THE BULLETIN | JANUARY / FEBRUARY 2009
The Top 10 Risk Management Issues for California Medical Office Practices By Kathleen Stillwell, RN, MPA, HAS What are the most frequent risks facing the medical office practice today? What strategies can minimize risks that might result in patient problems and professional liability claims? The following list identifies frequent risk management issues and suggests strategies for your medical office practice. 1. Patient Termination: The Medical Board of California advises that physicians must provide emergency care and prescriptions to a patient for at least 15 days before termination. Give notice of the termination in writing and include the termination date in the letter. Send the termination letter by certified mail, return receipt requested, and by regular mail. Be sure to keep the return receipt and a copy of the letter in the patient’s medical record. Do not refill the patient’s prescriptions beyond the termination date. [Reference: CMA ON-CALL document #0805, “Termination of the Physician-Patient Relationship,” www.cmanet.org.] 2. Test Results Follow-up: Ensure the practice has a system in place for tracking all tests ordered. Follow up on test results that do not come back to the office. The physician should review and initial all test results prior to filing them in the patient’s medical record. The physician should advise the patient of any abnormal test results. 3. Missed Appointments: The practice should have a formal missed appointment tracking system. Follow up with the patient by telephone to determine why the patient failed to arrive and to reschedule the appointment. Document missed appointments in the patient record. Send
a letter to patients who repeatedly miss appointments, explaining the importance of follow-up care to their overall health. At the point established by your office policy, consider terminating the patient-physician relationship. 4. Scope of Practice: Medical office staff includes a variety of health care
Face it—your practice is a minefield of risks. But there are things you can do to avoid the most frequent ones. professionals. Never allow medical office personnel to act outside the scope of their job descriptions, licensures, or certifications. Do not refer to medical assistants as “nurses,” and do not imply to patients that a member of your office staff is licensed or certified, if he or she is not. Do not allow personnel to manage technology or medical equipment, unless they have received appropriate training and, if necessary, are certified to operate the equipment. 5. Medication Management: During each visit, review the medication list with the patient (including all overthe-counter medications) and update accordingly. Provide the patient with a written medication list that includes dosage, directions for use, and side effects. There are many drug-drug and fooddrug incompatibilities. Review a drug’s side effects and interactions with the patient. If the office distributes medication
samples, record the medication lot number in the medical record. In the event of a medication recall, the practice must have a system in place for identifying samples that have been distributed. 6. Documentation: Documentation is your primary defense in the event of a lawsuit — additionally, the medical record is the method for clinicians to communicate about the patient’s plan of care. Remember to document the medical record objectively. Never point fingers at other physicians or clinicians. Do not impeach the integrity of the medical record by altering the record. Be sure to use approved abbreviations and to write legibly. If you use an electronic medical record (EMR), ensure that the system has a reliable backup and an appropriate disaster recovery program. 7. Dealing With a Disruptive Patient: Do not allow a disruptive patient to disturb your practice, to abuse office staff, or to threaten the safety of staff or other patients. Set boundaries and learn to say “no” to disruptive patients. If a patient becomes violent, call 911. Do not hesitate to terminate a disruptive patient from your practice. 8. Communication: Health literacy is an increasing risk issue for providers and patients. A patient’s limited understanding of medical and prescription instructions results in increased risks for the provider and the patient. Ensure that the patient understands instructions. Document the name and relationship of anyone acting as a patient’s translator. Consider using the Ask Me 3 communication tool for your patients. Ask Me 3, a free educational program sponsored by the National Patient Safety Continued on page 38
PAGE 22 | THE BULLETIN | JANUARY / FEBRUARY 2009
(November 2008 Issue, www.memag.com)
Rashid Elahi, M.D Inc Kidney Disease and Hypertension Dr. Elahi has moved his practice to a new location at 200 Jose Figueres Ave Suite 320. Dr. Elahi is Board Certiﬁed by the American Board of Internal Medicine as a Diplomat in Nephrology and Internal Medicine. He is dedicated to provide high quality care for patients with Kidney Disease and Hypertension. He brings his experience and knowledge from his fellowship at UC Davis Medical Center in Sacramento, CA and 10 years of Private Practice. Dr. Elahi is accepting new patients and accepts all health care plans.
If you would like to schedule an appointment, please give us a call at: Phone: (408) 937-9009
200 Jose Figueres Ave Suite 320, San Jose, CA 95116 PAGE 23 | THE BULLETIN | JANUARY / FEBRUARY 2009
MEDICAL RECORDS Answers to Your Most Commonly Asked Questions The following was obtained from NORCAL Mutual Insurance Company and the California Physician’s Legal Handbook (CPLH), a publication of the California Medical Association. CPLH is the only comprehensive legal guide written especially for California physicians. CPLH provides physicians with current laws, regulations, and court decisions related to medical practice in California. Who Can Exercise the Patient’s Right to Access the Medical Record? In California, according to CMA, “Generally speaking, all current and former adult patients, minor patients (in some circumstances), parents of minor patients (with exceptions), patient guardians or conservators, and deceased patients’ beneficiaries or personal representatives are entitled to inspect and make copies of the patient’s medical record information upon written request and payment of reasonable clerical costs.” Agents appointed Power of Attorney for Health Care and anyone acting as a lawful surrogate are also authorized to obtain the patient medical record information. Allowable Copying Charges The first step in determining the appropriate charge for copying medical records is to identify who is requesting copies. California law sets forth allowable charges for copying records for patients (as well as for attorneys); however, the following information is limited to allowable patient charges. The CMA’s On-Call Document #1150: “Patient Access to Medical Records” provides more detailed guidance
on these charges, as well as acceptable charges to parties other than patients. Many practices wonder if they can charge a flat fee for copying records. Charges set forth by statute do not allow for a flat fee. Prudent risk management practice would be to break out costs (i.e., copying versus clerical fees), based on accepted hourly rates. (Refer to CMA OnCall Document #1150, “Patient Access to Medical Records.”) It is also important to remember that where California law may allow recovery for certain costs, HIPAA Privacy
The first step in determining the appropriate charge for copying medical records is to identify who is requesting copies. Rules (45 C.F.R. §164.524 (c)(4)) may differ. For example, HIPAA does not allow practices to charge patients for clerical costs, where California law does. Practices may still, however, charge attorneys for clerical costs. Allowable Copying Charges for Patient Requests (California Health & Safety Code §§123100 et seq) When a patient requests a copy of his or her medical record, a physician may charge up to $.25 per page, or $.50 per page for copies from microfilm. Although
the law allows for copying charges, the CMA encourages physicians to waive these charges if the patient is unable to pay. Health care providers may charge for “reasonable clerical costs incurred in making the records available.” NOTE: clerical costs incurred in making the copies are included in the copying costs stated above. How long does a physician have to send the copy of medical records upon request? If the request for the records is made in writing, the physician must provide copies within 15 days. The physician can charge a reasonable fee for the cost of making the copies. If the physician’s office advises that a fee will be charged for the records, the medical records do not need to be provided until the fee is paid, however, records should not be withheld if the patient is unable to pay. How long should medical records be retained? If possible, medical records should be retained indefinitely (e.g., for as long as 25 years or more following the patient’s last office visit). The primary purpose of retaining medical records is to provide for the continuity of patient care. Retention of medical records is also important, in order to establish facts regarding the patient’s condition and course of treatment should those facts ever come into question (e.g., in an audit or a subsequent lawsuit involving the patient and the physician or another party). Finally, the law requires retention of certain medical records for specific periods of time.
PAGE 24 | THE BULLETIN | JANUARY / FEBRUARY 2009
Don’t be in turmoil when reviewing your health insurance! • • •
Health insurance premiums are on the rise again. You are going to feel pressure to change your benefit plan design. Again.
As each insurer has so many different options, it makes it difficult to determine which plan is best for you and your practice. With the time consuming demands of running a practice, what’s a member supposed to do? The answer is easy, according to Roy Lyons, managing director at Marsh. “If you’re too busy to compare plans, seek help from a resource who is looking out for your best interests,” he says. Marsh is such a resource for Association members. They serve as the Association’s endorsed health insurance broker and consultant. Marsh’s representatives have been serving the needs of members in California for more than 30
account in minutes. Match it up with any qualified high deductible health plan and contribute up to $3,000 for individual coverage and $5,950 for family coverage in 2009.
years, so you can trust their knowledge and experience. Marsh offers you: •
No-obligation guidance, review of your current plan Receive comparative information on your current plan to make sure you’re getting the best deal for you and your practice—and not paying more than you need. Access to a variety of health insurance plans from multiple insurers Marsh has different solutions available to you and will help determine the best one for you and the best one for your practice. (They don’t have to be the same!) Health Savings Accounts Go online to marshaffinity.com and open your own health savings
Tools to help you stay current on health and benefit issues Marsh understands that staying current on the latest issues can be challenging for you. That’s why once you obtain your group health benefits through Marsh, you’ll have access to Mercer Select HRKnowHow—at no cost. This free resource provides you with online health and benefit news, useful tools, checklists, and other valuable HR resources.
So, to avoid turmoil before your medical insurance renewal arrives, please call a Marsh Client Service Representative at 800/842-3761.
THE DIABETES SOCIETY IS THE ANSWER TO EFFECTIVELY MANAGING BLOOD GLUCOSE LEVELS IN YOUR DIABETIC PATIENTS The Diabetes Society is an independent non-profit organization founded in San Jose as a one-stop shop for diabetes education and support in the communities you serve! Services Offered: • ADA certified 3-step diabetes self-management program • Nutrition education and counseling • Free meters and instruction • Group classes (English and Spanish) • Support Groups (English and Spanish) • Insulin start appointments and pump training • Weight loss consultation and carb counting • Children’s diabetes camps throughout California Easy referral process with a variety of fee options including most insurance plans, Medicare and local IPA’s
> If you never thought about us for your patients, now is the time < For more information or brochures: 1165 Lincoln Avenue, Suite 300, San Jose, CA 95125 (408) 287-3785 Fax: (408) 287-2701 Email: email@example.com
PAGE 25 | THE BULLETIN | JANUARY / FEBRUARY 2009
NORCAL itm Your Comm
s Nothing Le
Parrish ociation William C. Medical Ass ty n u o C ra Santa Cla W ay 700 Em pey 95128 A C , se Son Jo
nce utual Insura NORCAL M all Street. I t a th l e n a P W ker Advisory p and dow n lly Dear Bill, rs of our Bro at sent shockwaves u CAL remains financia e b m e m e th th R d O is re N is u , cr ss ur edit rea roach that meet o re to the cr personally stment app Recently, I w accounts cant exposu t operational and inve e ifi n n k g e si se o n ly as den ctive C om pany h e to our pru wth. We continue to a em that du ro th g d g e d in o in g m re r on is poised fo ability. In from our st secure and uidelines. ce n e mpanies fid n gg surance co n draw co in r ca e L th A o underwritin C R ith NO ss w an admitted insured with ative to doing busine policies on tly s n te e ri rr w cu L s rn A n ntial future NORC er physicia ttractive alte against pote decisions. ty t ri n e cu m Your memb r members have an a se st d e n v ty a d in you erwriting an ditional safe N O R C AL, e risky und provides ad d t a h m ig e rs v e a v h o that may regulatory associated NORCAL is basis. The t analysts. e e tr . S ty ithstand ll a in a W rt lders. To w , not to o rs h e y n f market unce lic w o o p rr e u yhold standard o s of o riting to the r to our polic ctices and reputation e rw h e sw d ic n n h a u w e , s: w m l company, nt to safeguard the pra n time-tested principle ssful dividend progra As a mutua e we rely o uely succe ur commitm o the market, nd our uniq a in s; ty zealous in lu in a rp rt su ce r lde and un le policyho lders. turbulence em ber a formidab g ur policyho in o in ta to in n s of your m a d io e ill e m lly n 8 e 5 care; m th 3 t $ e ill be carefu to me d a total of er needs w g with you ld in o rk h o y o has returne w h lic w o to p rs be rrent rward f your m em ons and cu and look fo odate any o artnership w submissi m p e r n m u o ll o A y cc . a e te a to We appreci ring this challenging tim everything they can du ill do w s. e rs ic te ct ri ra rw physicians p de ical any and our un g their med If you have considered ut protectin cians first. o si eting b y a rk h a p d e r M e rn & b ce ur m em of Sales o t y n t e u may be con d p si to re e P tinu ice ith either V elp you con w we can h te to call and speak w o h w o . 0 kn 0 7 s t 415/397-9 Please let u tsoever, do not hesita Partridge, a ha questions w r Sales Manager Keith ll, o Molly Farre
ri nseri seu nS u S s s e e m m Ja a J
seri James Sun CEO & President
CALCompany NORsu rance
ual In 1966 l.com ^ Mut CA 94111.norcalmutua Francisco, w w an w S 0 15 20 15) 835-98 treet, Suite 51 Fax. (4 560 Davis S 00) 652-10 (8 00 97 (415) 397-
PAGE 26 | THE BULLETIN | JANUARY / FEBRUARY 2009
58th Annual Yosemite Postgraduate Institute For Primary Care Physicians
CONTINUING MEDICAL EDUCATION COURSE ANNOUNCEMENT
Yosemite Lodge, Yosemite National Park April 3-5, 2009 $325 Physicians; $275 Allied Health Professionals (RN, NP, PA); $100 Medical students, interns or residents Up to 16 hours, Category 1 and Prescribe Credit
TOPICS INCLUDE: Psychiatric Challenges, Psychotropics, Aging, Cardiovascular Diseases, Hypertension, Endocrine Problems, Dermatology, Stroke, Headaches MORE INFORMATION: Fresno-Madera Medical Society; P.O. Box 28337; Fresno, CA 93729-8337 (559) 224-4224 ext. 18 • FAX: (559) 224-0276 • firstname.lastname@example.org PAGE 27 | THE BULLETIN | JANUARY / FEBRUARY 2009
SEHAM F. EL-DIWANY, MD
The Matibabu Project Matibabu Clinic was established in 2003 to serve the population of Ugenya, Kenya, an impoverished rural area where 40% of the population have active AIDS or are HIV positive, with high prevalences of Malaria, worms, TB, sickle cell disease, and a host of infectious diseases are found. Kaiser Permanante is a proud supporter of the Matibabu Clinic. Last summer, SCCMA member Seham El-Diwany, MD volunteered to work for three weeks in Matibabu’s permanent clinic in Ukwala, an extremely poor rural area. The team with whom she served consisted of a Kenyan doctor, two nurses, a pharmacist, a receptionist, and an interpreter. From 8:30 a.m. to 5:30 p.m., people lined up to be seen at this almost-free clinic. Some walked or biked for hours to get there. Dr. El-Diwany said “It was a humbling experience, working under such difficult conditions, with limited resources, and yet making a huge difference in the lives of many.” The Matibabu Clinic serves as a model for AIDS treatment in rural areas.
Huy Nguyen, DO
First Single Incision Gallbladder Removal in Northern California SCCMA member and San Jose surgeon is the first in northern California to remove a patient’s gallbladder using a single incision. Huy Nguyen, DO performed the first procedure on September 9, 2008 at Regional Medical Center of San Jose and has since completed more than a dozen of the minimally invasive procedures. Most patients are discharged the same day and return to normal activities, including golf and scuba diving, as quickly as one week. The technique was introduced last summer, and few hospitals in the nation are able to offer this option to patients. Dr. Nguyen is a community physician who practices at Regional Medical Center of San Jose, where the laparoscopic operating suite is designed to maximize advances in minimally invasive surgical techniques. •
Unlike traditional laparoscopic gallbladder surgery where instruments are inserted through four incisions, in the revolutionary new procedure, the surgeon uses a single port in the patient’s navel.
The tools include a camera and instruments to cut and suture. The physician watches a high definition video monitor to guide the course of the surgery.
Patients are attracted to the aesthetic appeal of having fewer post-operative scars, but doctors say the single incision can mean faster recovery, less risk for infection or bleeding, less pain, and potentially reduced costs because less instrumentation is needed.
Single incision laparoscopic surgery is a rapidly developing technique. Future uses in development include appendectomies, some colon resections, weight loss surgery, and gastrectomies.
750,000 Americans undergo gallbladder removal annually, most frequently because associated attacks involve intense pain that can resemble a heart attack and that interferes significantly with work and daily activities.
For information on the Matibabu Foundation, you can visit their website at http://www.matibabu.com/.
Dr. El-Diwany and her team at the Matibabu Clinic
PAGE 28 | THE BULLETIN | JANUARY / FEBRUARY 2009
Tracy Zweig Associates A
Nurse Practitioners ~ Physician Assistants
Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 -919-9141 o r 805-641-9141 FA X : 805-641-9143
t z w eig @tracyzweig.co m w ww.tracyzweig.co m
When you have questions about eating disorders...
Eating Disorders Resource Center Medical education (CMEs) for you and your staff to help you address the needs of patients with eating disorders Advocacy for insurance issues S.C.C.M.A. Professionally-facilitated support groups for your 8-12-08
patients and their family members (no fee; twice a month)
...we’re here to help.
Awareness, Recovery, Advocacy www.edrcsv.org 408-559-5593
An online and printed directory of local professionals who specialize in treating anorexia, bulimia, and other eating disorders. Our website provides useful links and information for patients
PAGE 29 | THE BULLETIN | JANUARY / FEBRUARY 2009
AMA Policy Highlights Stand-out resolutions from the Interim Meeting also wants the CMS to give it the 2007 PQRI data set file.
By Chris Womack Reprinted with permission of Southern California Physician (www.socalphys.com)
Council on Medical Service Report 4 The AMA will ask the Federation of Medicine for comments about Medicare payment reform strategies. The association will give testimony and comments from the House of Delegates and the reference committee to the Council on Medical Service, as it develops recommendations for
The American Medical Association’s November Interim Meeting helps set the nationwide organization’s policy. Here’s a look at some of the meeting’s stand-out resolutions.
Requiring Children’s Health Insurance Resolution 610 By AMA vote, it’s now a priority for the organization to require adequate health insurance for all children. The resolution reaffirmed existing policy.
Participating in Medicare
its report to the 2009 House of Delegates Annual Meeting. The AMA will also encourage state medical associations and national specialty societies to chime in with their ideas and strategies by January 9.
Studying the Medical Home Concept Resolution 804
Resolution 216 The AMA will ask the U.S. Centers for Medicare and Medicaid Services to give physicians two chances each year to decide their participation in Medicare. One chance would be in the middle of the calendar year and the other chance would be at the end of the calendar year. Resolution 219 The CMS Physician Quality Reporting Initiative (PQRI) needs further improvements, and the AMA will continue to press for them, by using methods that would include, for example, early education and outreach to physicians. The AMA also wants the CMS to provide doctors confidential interim and final feedback reports about potential problems in their PQRI reporting, as well as easier access to feedback reports, and meaningful dispute-resolution processes. The AMA
The “Joint Principles of the Patient-Centered Medical Home” is now officially AMA policy, and the association will continue to study the patient-centered medical home concept, particularly in the areas of funding sources and payment structures.
Comparing Effectiveness of Treatments Council on Medical Service Report 5 The AMA calls for the creation of a federal agency or institution that performs comparative effectiveness research on drugs, biologics, imaging and laboratory tests, medical devices, health services, or combinations of these items. Among other requirements, the House of Delegates adopted guidelines calling for it to be objective and independent, producing valid, scientifically rigorous research.
Changing the Constitution and Bylaws Council on Ethical and Judicial Affairs Report 1 Legally permissible opportunities for physician self-referral will be guided by new AMA ethics policy that makes clear that a physician’s obligation is to the patient first. Resolution 1 The AMA House of Delegates voted to work with the Joint Commission and others to define disruptive physician behavior. The definition will include actions amounting to true abusive behavior, and it will specify rules for an appeals process for physicians accused of disruptive behavior. The AMA will also make sure that such allegations are handled by the organized medical staff through established bylaws. Resolution 6 The AMA will help medical staffs and hospitals identify disruptive behavior at all levels of an organization as distinct from other types of conduct. The AMA will also ask the Joint Commission for a one-year moratorium on a new standard of disruptive behavior, to allow medical staffs time to bring bylaws into compliance. The new standard was effective on January 1, 2009.
Banning Trans Fats Resolution 210 Trans fats are now on the AMA’s blacklist. The association voted to support
PAGE 30 | THE BULLETIN | JANUARY / FEBRUARY 2009
state and federal legislation banning their use in restaurants and bakeries in the United States.
the high school level onward. The AMA’s goal is to enroll, retain, and graduate increased numbers of underrepresented students.
Discouraging Text Messaging
Fighting Vaccination Exemptions
Resolution 217 Following a trend of concern nationwide, the AMA voted to ask physicians to explain the dangers of text messaging while driving or operating other machinery. The association will support state legislation seeking to forbid text messaging in those circumstances.
Resolution 922 The AMA will provide vaccine safety and efficacy information to states to encourage more stringent requirements of parents and guardians seeking “personal belief exemptions” that allow children to go without being vaccinated as they should be. The association will also create educational materials on vaccine benefits and the excellent safety record for them. Along with other organizations, the AMA will support vaccinations and fight the spread of false information about them.
Increasing Diversity Resolution 908 Physician diversity should reflect patient diversity, so the AMA recommends that medical schools consider gender, race, culture, economic status, and other measures in structuring programs. The AMA will also support the development of new programs and the enhancement of existing programs that will identify and prepare underrepresented students from
Reclassifying Marijuana Resolutions 910 and 912
marijuana reclassification for further study. Both called for reclassification from Schedule I to a less serious category, and one resolution called for an end to criminal prosecutions of physicians and patients who are following state medical marijuana laws.
Creating New “Green” Policies Council on Science and Public Health Report 1 Responsible waste management became AMA policy with the adoption of this report at the November Interim Meeting. The AMA would promote appropriate recycling and waste reduction; the use of ecologically sustainable products, foods and materials; and the development of non-toxic, sustainable, and ecologicallysound products. The association will also support building practices that conserve resources, as well as community “green” initiatives.
The AMA referred resolutions on marijuana medical use and research
Thinking about electronic medical records? What about your paper records? If you are planning going to do with all those records into records to a CD alternative:
to move to an electronic medical record system, what are you your paper patient charts and billing files? Consider scanning a digital database with deliverExchange™. Let us scan your or DVD, and realize the benefits of this cost-effective
Safe secure storage that you control • Records are accessible 24/7 Files can be printed out or electronically transmitted • Save time spent filing and retrieving records • Eliminate lost or misfiled records • Save space and storage costs • Keep a copy for backup, security •
We pick up your records, scan them at our imaging unit in San Jose, produce quality images on CDs or DVDs, and handle the destruction of the paper records. 2054 Zanker Road San Jose, CA 95131 Contact: Liz Allan phone 408.436.1701 ext.131 fax 408.436.1625
You may not know our name, but if you practice in Santa Clara county you know our service. For over 30 years, SOURCECORP Deliverex has been the vendor of choice for record management in the Bay Area.
PAGE 31 | THE BULLETIN | JANUARY / FEBRUARY 2009
Insurers Updating Contracts for Language Access Regs CMA has updated ON-CALL document #0813, “Language Interpreters,” to address various new health plan contract amendments related to the Language Assistance Program (LAP) regulations that will take effect in 2009. Because the law leaves it up to each insurer to establish its own LAP standards and procedures, physicians are understandably concerned about what these regulations mean to their practices. (ON-CALL documents are free to members at http:// www.cmanet.org/member.) The regulations, recently adopted by the Department of Managed Health Care (DMHC) and the Department of Insurance (DOI), require health insurance companies to provide free interpretation and translation services in “threshold languages” to enrollees with limited English proficiency (LEP). The DMHC
regulations took effect on January 1, 2009, and the DOI regulations April 1. The regulations place the financial responsibility for compliance on the insurers, except when delegated financial responsibility has been negotiated separately. Previously proposed regulations would have placed the burden on physicians to provide these services. Physicians’ obligations will vary by insurer, but, in general, physicians will be required to: inform patients of the availability of translation and interpretation assistance at the point of service; document when and if LEP patients refuse language assistance; and complete provider language capability disclosure forms so that the health plans can assess the LAP needs of their enrollees. As each insurer’s LAP standards may vary, it is critical that contracted physicians are provided with adequate information
about those standards. Some plans, such as Blue Cross, have already forwarded the details of their programs to physicians through contract amendments and updated program manuals. Other plans, such as United Healthcare, have merely required that physicians comply with their LAP without disclosing the underlying details. CMA believes this is insufficient and urges physicians faced with the latter scenario to contact the plan so that they understand their obligations. CMA has already discussed this issue with United, and the insurer has agreed to provide physicians with additional detail about its language assistance program. CMA is closely monitoring the situation and encourages physicians to report any burdensome requirements to CMA. Contact: CMA’s Reimbursement Helpline, 888/401-5911 or email@example.com. (CMA Alert, November 10, 2008 issue)
Checked Your Medical Board Profile Recently?
Save the Date: 2009 Leadership Academy
Physician profiles have been available to the public on the Medical Board of California’s website since 1997, as required by Business and Professions Code sections 2027 and 803.1. CMA encourages physicians to check their profiles for accuracy and advise the board of any corrections, especially changes to their addresses of record. The board cautions physicians against using their home addresses, because the addresses become widely available to the public on the Internet. You may designate a post office box as your address of record but, by law, you also must provide the medical board with a street address. In this case, the street address remains confidential, and all official correspondence, such as license renewal notices, go to the post office box. For more information, including a change-of-address form, visit http://www.cmaalert.org. Contact: Yvonne Choong, 916/551-2884 or firstname.lastname@example.org.
Mark your calendars for CMA’s 12th Annual California Health Care Leadership Academy, April 24-26 at the Disneyland Hotel in Anaheim. This year’s conference will feature presentations on health system reform in a new era of Washington politics, the “medical home” and other emerging models for the delivery of quality care, the promises and perils of hospital EHR initiatives, health disparities, and more. Attendees will also have the opportunity to participate in breakout workshops on topics ranging from survival strategies for practicing in a turbulent economy, to mitigating malpractice risk, developing leadership skills, and more. The California Medical Group Management Association is partnering with CMA on the 2009 conference and will sponsor an exhibit hall with more than 50 vendors. Contact: Roger Purdy, 916/444-5532 or email@example.com.
(CMA Alert, January 12, 2009 issue)
(CMA Alert, December 22, 2008 issue)
PAGE 32 | THE BULLETIN | JANUARY / FEBRUARY 2009
State Supreme Court Outlaws Balance Billing, Increases Burden on Stressed ER System The California State Supreme Court struck down the practice of “balance billing,” forcing physicians and hospitals to eat the cost of emergency medical care that HMOs refuse to cover. When HMOs don’t pay the full cost of ER care for their policyholders – a growing trend – doctors must bill for the outstanding balance, creating an awful burden for both physician and patient. The practice is known as balance billing. CMA supports a solution that protects doctors and patients by requiring HMOs to pay the bill for emergency services. By outlawing balance billing without a realistic remedy, however, the court has placed another strain on financially struggling emergency rooms and the physicians who work there. “As a trauma surgeon, my number one priority is to save lives and protect the
health of my patients,” said CMA President Dev A. GnanaDev, MD. “This court ruling basically says if I do my job as I see fit and HMOs don’t want to pay, tough luck, go to court. I signed up to be a doctor, not a lawyer.” The court’s failure to solve the underpayment problem will stress the already beleaguered emergency care system. More than 70 California ERs have closed since 1990. In addition, the state’s emergency rooms performed more than $1 billion in uncompensated care in the year ending June 30, 2007, the most recent statistics available, according to the Office of Statewide Health Planning and Development. “There is no doubt this ruling adds to the growing woes of California’s emergency rooms,” Dr. GnanaDev said. “Sadly, this
will reduce the availability of emergency care throughout the state.” CMA is exploring all of its options to ensure physicians have adequate recourse when HMOs fail to pay reasonably for emergency services. Organized medicine remains steadfast in its efforts to ensure that noncontracted physicians are properly paid for services provided to patients. To assist in these efforts, CMA has distributed a survey on the issue of underpayment for out-of-network services. All physicians are urged to complete the survey as soon as possible. For more information, including a link to the survey, visit http://www.cmaalert.org. Contact: 800/786-4CMA (4262) or firstname.lastname@example.org. (CMA Alert, January 12, 2009 issue)
Governor Proposes Cuts and Taxes to Address $40 Billion Shortfall The Schwarzenegger Administration recently unveiled a new budget proposal to address the $40+ billion shortfall facing California over the next 18 months. The proposal is a mix of roughly $14.3 billion in increased taxes, $17.4 billion in spending cuts, $5 billion in projected increased revenues from a revamped state lottery, and an additional $5 billion from borrowing. While the Administration continues to honor the injunction against Medi-Cal provider rate cuts that CMA helped obtain earlier this year, there are some cuts which may be of interest to physicians: • $275 million saved by eliminating the California Children and Families Commission (First 5 Commission) and redirecting all state Prop 10 funds and half of local Prop 10 funds
to children’s programs under the Department of Social Services. •
$298 million saved by eliminating certain optional Medi-Cal benefits for adults, including dental, optometry, and psychology.
$85 million shifted from the 2008-9 fiscal year to the 2009-10 fiscal year by delaying checkwrite payments to Medi-Cal fee-for-service providers one month in June 2009. This is in addition to a previously authorized two-week delay.
$52.4 million saved by reducing Medi-Cal reimbursements to public hospitals, with an increase in the same amount in federal funds to unspecified public health programs.
The Governor’s proposal also includes $14.3 billion in new tax revenue, including a temporary increase in the state sales tax, expansion of the sales tax to cover some previously untaxed services (does not include health care), a nickel-a-drink alcohol tax, a new tax on oil production, a $12 hike on vehicle registration fees, and reduction of the dependent care exemption on state income tax returns. This and other legislative budget proposals continue to be subject to much debate at the Capitol. CMA will continue to monitor the budget discussions and provide updates when relevant. Contact: Ned Wigglesworth, 916/4445532 or email@example.com.
PAGE 33 | THE BULLETIN | JANUARY / FEBRUARY 2009
(CMA Alert, January 12, 2009 issue)
Physicians Can Earn 2% Medicare Bonus for e-Prescribing
CMA Supports Regulations to Reduce Diesel Emissions
Physicians who use qualified e-prescribing systems to transmit prescriptions to pharmacies can earn a bonus payment of 2% of their total Medicare allowed charges during 2009. This new incentive is in addition to the 2% bonus for participating in the quality reporting program and the 1.1% general payment update. To be eligible for the e-prescribing bonus, the services linked to e-prescribing measures must make up at least 10% of your Medicare charges for the year. You must also use a qualified electronic prescribing system that can: • Generate a complete medication list with available data from pharmacies and benefit managers. • Select medications and transmit prescriptions electronically (not via fax) following applicable federal standards, after warning the prescriber of any possible safety issues associated with the drug orders. • Provide information on lower-cost, therapeutically appropriate alternatives. • Provide drug plan information, such as formularies, patient eligibility, and authorization requirements. For more details on the e-prescribing bonus, see the Center for Medicare and Medicaid Services’ “Practical Guide to the E-prescribing Incentive Program,” available at http://www.cms.hhs.gov. For more information on e-prescribing in general, see eHealth Initiative’s “Clinician’s Guide to Electronic Prescribing,” a how-to guide to help physicians make informed decisions about how and when to transition from paper to electronic prescribing systems. Contact: Desiree Rice, 916/551-2865 or firstname.lastname@example.org.
As a participating member of the Health Network for Clean Air, CMA has signed on to a letter encouraging the California Air Resources Board (CARB) to implement proposed regulations to reduce emissions from diesel vehicles. The regulations would require existing heavy-duty diesel vehicles to be upgraded or replaced to comply with specified particulate matter and oxides of nitrogen emission standards. These harmful pollutants are associated with increased emergency room and doctor’s office visits and contribute greatly to health disparities in communities along the goods movement chain. CARB staff estimates that the implementation of these regulations will reduce premature deaths by roughly 3,300 between 2010 and 2025. CMA has extensive policy supporting greater regulation to reduce the emission of air pollutants, including a resolution passed at last year’s House of Delegates (715-08) that calls on CMA to “support efforts to significantly reduce the amount of particulate pollution from diesel sources.” CMA members testified about the public health impacts of poor air quality at public hearings on these regulations on December 11 and 12 in Sacramento. Contact: Delilah Clay, 916/551-2569 or dclay@cmanet. org. (CMA Alert, December 8, 2008 issue)
(CMA Alert, December 22, 2008 issue)
Medical Board Changes CME Reporting Requirements New CME reporting requirements recently passed by the medical board take effect in 2009. Physicians will now be required to complete 50 CME hours during every two-year licensure period. Previously, physicians were required to complete 100 hours every four years. CME will also be calculated based on the physician’s personal license renewal date (the last day of the month of your birthday), not the calendar year. CMA’s Institute for Medical Quality’s CME Certification Program, now in its 32nd year, documents and verifies physician participation in approved postgraduate education and other CME activities.
IMQ has modified its processes to adapt to the medical board’s new reporting requirements. Reporting forms will be automatically mailed quarterly to physicians with license expiration dates in the following quarter. (IMQ’s CME reporting form is also available online at http://www.imq.org.) Once a completed form has been received by IMQ, the physician’s self-reported CME will be verified for compliance with medical board requirements. Certification acknowledgements will be mailed to physicians within four weeks of receipt. In addition to satisfying the medical board’s licensure requirements, IMQ’s
CME certification, when completed annually, also satisfies eligibility requirements for IMQ’s Certificate in Continuing Medical Education and AMA’s Physician Recognition Award. IMQ’s CME certification is $29 for members, $49 for nonmembers. Physicians also can request that their CME certification information be sent to hospitals, health plans, specialty societies, and others for credentialing or membership renewal purposes, without additional charge. Contact: Paulette Richardson, 415/8823387 or email@example.com.
PAGE 34 | THE BULLETIN | JANUARY / FEBRUARY 2009
(CMA Alert, December 22, 2008 issue)
MEMBER NEWS & HAPPENINGS
In Memoriam William F. Baxter, MD *Otolaryngology 5/12/24 – 8/22/08 SCCMA member since 1958
Julius Glick, MD Pediatrics 3/10/20 – 1/4/09 SCCMA member since 1969
Philip L. Blumenthal, MD *Family Practice 2/20/18 – 11/10/08 SCCMA member since 1961
Norman S. Greenberg, MD *Pediatrics 10/3/33 – 6/16/08 SCCMA member since 1966
Gerald L. Colonica, MD *Family Practice 10/9/24 – 1/14/09 SCCMA member since 1953
Paul F. Hoar, MD *Anesthesiology 12/27/42 – 12/31/08 SCCMA member since 1983
Ralph D. Cressman, MD *General Surgery 1/17/09 – 10/11/07 SCCMA member since 1941
Takashi Inouye, MD General Practice 12/17/19 – 2006 SCCMA member since 1957
Eugene C. Feldman, MD *Pediatrics 5/21/35 – 4/08 SCCMA member since 1987
S. Fred Kaufman, MD *Internal Medicine 6/28/21 – 10/31/08 SCCMA member since 1951
SAVE THIS DATE SCCMA 2009 Awards Banquet Tuesday, June 2, 2009 6:30 P.M. Fairmont Hotel San Jose
Leslie W. Knott, MD Public Health & Gen Preventive Medicine Physical Medicine & Rehabilitation 6/14/11 – 1/4/09 SCCMA member since 1967 Malcolm B. Leslie, MD *General Surgery Hypnosis 1/4/30 – 4/11/07 SCCMA member since 1963 Warren E. Mayes, MD *Anesthesiology 5/11/28 – 12/4/08 SCCMA member since 1962 Cesar M. Mayo, MD *Neurology Electromyography 2/23/39 – 11/21/08 SCCMA member since 1972
Richard L. Miller, MD Pediatrics 10/15/33 – 9/14/08 SCCMA member since 1966 Maurice Rappaport, MD *Psychiatry 2/9/26 – 10/12/08 SCCMA member since 1966 Past SCCMA President 1981-82 Harold N. Schell, MD *Family Practice 10/30/21 – 10/15/08 SCCMA member since 1952 Galal T. Shaker, MD *General Surgery 10/11/18 – 1/19/09 SCCMA member since 1967
New SCCMA Members Name Carmie Chan
City San Jose
My Phuong Mitarai
PAGE 35 | THE BULLETIN | JANUARY / FEBRUARY 2009
CLASSIFIED ADS office space for rent/lease MEDICAL OFFICE SPACE FOR LEASE • East San Jose 1,380 sq. ft. excellent medical suite across from Regional Medical Center. Available immediately. First floor, with lab and xray suites in the building, to make it convenient for your patients. Lots of parking available. Great visibility at corner of N. Jackson and Montpellier Dr., located at 244 N. Jackson Ave. Call Tania at 408/923-0257.
MEDICAL/DENTAL OFFICES FOR LEASE • WEST SAN JOSE/ CAMPBELL/LOS GATOS/WILLOW GLEN
MEDICAL SUITES • GILROY
OFFICE EXAM ROOMS TO LEASE
First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.
Two nice and large exam rooms (dedicated), shared waiting room. Available five days a week, 2585 Samaritan Drive, San Jose. Please call 408/356-7788 for more information.
MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA
MEDICAL OFFICE SUITE FOR RENT • SAN JOSE
Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.
Medical office suite for rent at 93 N. 14th St. San Jose 95112. Contact Dr. Sajjadi at 408/294-1825 or 408/867-1111.
OFFICE SPACE FOR LEASE • SAN JOSE
Exceptional location for quality suites consisting of first floor: (1) 1,595 sq. ft. Second floor: (2) 1,030 sq. ft.; (3) 1,675 sq. ft. (combined 2,705 sq. ft.); (4) 1,500 sq. ft. (combined 4,945 sq. ft.). Tenant improvement allowances. Bldg. elevator. Paradise landscape. Minutes from hospitals. Excellent visibility and signage with ample parking. Easy access to Hwys. 17/880 & 85. Located at 2242 Camden Ave. (Bascom Ave.), San Jose. Call Sheldon at 408/377-7383.
MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital. Both units currently available. Call 408/355-1519.
MEDICAL OFFICE FOR LEASE/ SUBLEASE/SALE Office in close proximity to O’Connor Hospital for lease/sublease/sale. Please call 408/923-8098 for more information.
600–1,900 sq. ft. in West Valley Medical Building, second floor, elevator, separate entrance. Call Helen at 408/243-6911.
OFFICE SPACE FOR RENT • MTN VIEW Consult room and exam room available in shared office suite, near El Camino Hospital. Shared receptionist and billing services available if desired. Contact Len Doberne, MD at 650/967-8841.
OFFICE SPACE FOR SUBLEASE • MTN VIEW Two exam rooms and one doctor’s office, five days a week, shared waiting room, in Mountain View, on South Drive. Call 650/967-7471.
PRIME MEDICAL SPACE • PRIME SAN JOSE LOCATION 2,048 sq. ft. ready to occupy medical office, previously occupied by RAMBLC Pediatric Group. Located at 6140 Camino Verde Dr, San Jose, in the Santa Teresa Medical/Professional Center across from Kaiser Hospital. Call Virginia at 408/5280571.
OFFICE SUITE AVAILABLE Location is Highway 85 at De Anza. One suite available. Currently configured with 6 tx rooms/offices, entry, large master office with balcony. Street signage to 100,000 cars a day. Marble entry. Zoned medical/ office. No variance required. Looking for established business/practice that values prime location in beautiful building. Please be qualified. No start ups. Contact
OFFICE TO SHARE • LOS ALTOS Options include two exam rooms plus office. Newly remodeled office space perfect for cosmetic dermatologist, facial plastic, or plastic surgeon. Near El Camino Hospital. Call 650/804-9270.
PAGE 36 | THE BULLETIN | JANUARY / FEBRUARY 2009
BRAND NEW HIGH END MEDICAL CONDOS– DOWNTOWN LOS GATOS Design/build-to-suit opportunities for sale/lease. On-site parking. In the heart of prestigious downtown Los Gatos. Unit sizes 1,400 sq. ft. and up. Contact Matt–408/282-3835. www. colliersparrish.com/losgatos.
Dr. Newman at 408/996-8717. Brokers welcome if you have a client. Compare with space by Good Sam at $3.50 sq. ft.
INTERNIST MD LOOKING FOR ANOTHER MD TO SHARE OFFICE SPACE IN SARATOGA Starting at $600/unit/mo., this 900 sq. ft. office provides adequate space for a small practice at least four days/wk. Three units available: two treatment rooms (9 ft. 10 in. x 8 ft. 8 in.), one large consultation room (12 ft. 4 in. x 8 ft. 11 in.). Call Lisa 408/516-4537.
OFFICE SPACE FOR SUBLEASE • LOS GATOS 1-2 exam rooms across from Los Gatos Community Hospital. Available Monday, Wednesday, Friday. $900/month or best offer. Call 408/309-3050.
PRIVATE PRACTICE for sale
Established/Active Internal Medicine/ Primary care practice for sale. Work/ live in Coastal California. Enjoy best of everything. If interested, please call 831/345-9696.
Located near O’Connor Hospital on Forest Avenue. 950 sq. ft., three year lease, no triple net. Call 408/373-4165.
Providing Clinicians Quality Medical Transcription Since 1995 � Dictation Using 800 Phone System or Your Hand-Held Recorder � 24-Hr. TAT - STAT 2-Hrs. � HIPAA Compliant
State of the art medical space available to sublet on Bascom and White Oaks. Up to three exam rooms with shared common areas. Ideal for primary care or specialist. For more information, please contact Beth at 408/369-4210.
PRIVATE PRACTICE FOR SALE
MEDICAL/DENTAL OFFICE FOR LEASE
A+ TRANSCRIPTION SERVICE
MEDICAL SPACE AVAILABLE
IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.
Medical office space—800 sq. ft., rent $1,900 per month. Three exam rooms, one private doctor’s office, one toilet, receptionist area, and common share waiting area. Located at the back of El Camino Hospital. Please contact Stella 650/799-5922.
A newly upgraded Class A building offers a variety of spaces from 1,166 sq. ft. and up for medical/dental use at 3301-3351 El Camino Real, Atherton. Tenant improvement allowances available to design suite to meet your needs. Excellent onsite parking, close to Stanford and Sequoia. Trask Leonard, Bayside Realty Partners, 650/282-4620 or Alice Teng, Colliers, 408/282-3808.
Medical office for lease, 1,050 sq. ft., three exam rooms and a doctor’s office. Large waiting and reception room. Located on Altos Oaks Drive near El Camino Hospital. Call 650/575-6889.
PRIVATE PRACTICE FOR SALE
OFFICE SPACE FOR LEASE • MTN VIEW
ATHERTON SQUARE MEDICAL/ DENTAL BUILDING
MEDICAL OFFICE FOR LEASE • LOS ALTOS
GYN PRACTICE Good opportunity to take over a well established Gyn practice in a large office next to Los Gatos Hospital for minimal investment. Call for details 408/768-0816.
EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians Continued on page 38
Testimonials “ A+ Transcription makes us feel like we are their only client. Great work in terms of accuracy and rapid turnaround time.” Wendy Perston, Administrator – Cardiovascular Institute of Southern Oregon “A+ Transcription has provided my Physiatry and Pain Medicine practice with prompt, accurate transcription for many years. I strongly recommend this service to any clinician.” Mark J. Sontag, M.D. “Transition was seamless, prompt, accurate and very easy to work with. All my doctors are completely satisfied with A+ Transcription Service!” Ilona Garton, Administrator – Altos Oaks Medical Group “A+ Transcription Service has good turnaround time. Their team is accurate in transcribing what we dictate and most importantly, A+ is reliable!”Anthony DuBose, M.D. – Director, Workforce Medical Center
PAGE 37 | THE BULLETIN | JANUARY / FEBRUARY 2009
A+ Transcription Service 888 589-8283 e-mail: firstname.lastname@example.org
Classified Ads, continued from page 37 (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Dan R. Azar MD, MPH at 408/790-2907 or e-mail email@example.com for additional information.
condo/COTTAGE rentals BEACH HOME • RIO DEL MAR/ APTOS Two story, three bedroom, remodeled home, 1½ blocks from beach, available for weekend or weekly rental. Email firstname.lastname@example.org for details.
driveway and fenced yard. Rent $1,290 per month. Available immediately. Contact Carolyn Silberman 408/867-1815, or cell 408/221-7821, or email wwswolfe@aol. com.
WANTED PEDIATRIC PRACTICE Will buy Pediatric practice in South Bay. Call 408/455-2959.
FOR SALE BEAUTIFUL HAWAIIAN CONDO Poipu Beach, Kauai. Lovely 2 BR/2 BA condo, across street from ocean. Recently remodeled bathroom and kitchen with granite countertops, new carpeting throughout. Three lanais with ocean and mountain views, and the tropical gardens which make the Nihi Kai complex so special. $885,000. Call 650/949-3353.
MISCELLANEOUS MEDICAL OFFICE EQUIPMENT FOR SALE Reupholstered midmark exam tables with stirrups and storage drawers; Beam scales with height rod and wheels; Adjustable exam stools. Call 650/255-6907 or email: email@example.com.
Pajaro Dunes Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families
COTTAGE FOR RENT • SARATOGA Cottage in Saratoga. Retreat-like setting. Close to great hiking and biking trails. Close to Hwy 85. One large bedroom, living room, kitchen, and bath. Private
Owners Bill & Debbi Ricks 408-354-5613
Rental Agent Pajaro Dunes Company 1-800-564-1771
Top 10 Risk Management Issues, continued from page 22 Foundation, is available at www.askme3. org. 9. Patient Satisfaction: Listen to your patients, and obtain their input to learn about potential opportunities for improving your office practice. Review and evaluate all complaints with your staff. 10. Medical Record Retention: The California Medical Association (CMA)
has concluded that while a retention period of at least 10 years may be sufficient, it recommends that all medical records be retained indefinitely or, in the alternative, for 25 years after the last date of treatment. Destroy medical records appropriately, and maintain an inventory of all records destroyed. [Reference: CMA ON-CALL document #1160, “Retention of Medical Records,” www.cmanet.org.]
About the Author: Kathleen Stillwell is a regional patient safety risk manager for The Doctors Company. Reprinted with permission of San Diego Physician, the official publication of the San Diego County Medical Society.
PAGE 38 | THE BULLETIN | JANUARY / FEBRUARY 2009
Nationally Recognized California Pacific Medical Center’s Heart and Vascular Center is proud to be the recipient of several national recognitions and awards:
2008 HealthGrades® Distinguished Hospital Award for Clinical Excellence™, presented to California Pacific Medical Center, among the top 5% in the nation in terms of mortality and complication rates for 27 procedures and diagnoses.
HealthGrades® also ranked California Pacific: • Best in the San Francisco Area for Cardiology and Overall Cardiac Services • 5-star rated for CHF, AMI shed Ho and Atrial Fibrillation gui s
• Ranks first in the country in appropriate use of acute and discharge beta-blocker therapy • Discharges 100% of patients on lipid lowering medications • Has a rate of risk-adjusted mortality that is lower than the national bench marks for both ST-elevation and non-ST-elevation myocardial infarction patients.
Recent quarter results show that California Pacific:
This award reflects California Pacific’s commitment to a team approach in treating these patients, utilizing the expertise of physicians in cardiology, interventional radiology, vascular surgery, endovascular surgery and neurosurgery.
American College of Cardiology and the American Heart Association’s Silver Performance Award, presented for California Pacific’s results from the ACTION national registry for acute coronary syndrome patients. The award recognizes that a minimum 85% compliance rate has been sustained for overall adherence to guideline-based therapy in this patient cohort for 12 consecutive months.
Address service requested
A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION
700 Empey Way, San Jose, CA 95128-4705
PRSRT STD U.S. Postage PAID San Jose, CA Permit No. 503
$358 Million in Dividends Since 1975
We’ve Earned Straight A’s for 25 Years NORCAL achieved an “A”policyholder, financial rating froma piece A.M. Best, leading provider of insurance industry Over ratings, When you has become a NORCAL you own of onethe of the nation’s top medical liability insurers. the for pastthe past quarter century. Our financial stability has allowed us to return $358 million in dividends to NORCAL policyholder 34 years NORCAL has returned $358 million in dividends to our policyholder owners. Visit www.norcalmutual.com today,owners. Visit today, or call 800.652.1051. NORCAL. or callwww.norcalmutual.com 800.652.1051. NORCAL. Your commitment deserves nothing less. Your commitment deserves nothing less. NORCAL proudtotobe beendorsed endorsed by by the Medical Association NORCAL is is proud the Santa SantaClara ClaraCounty County Medical Association preferredprofessional professional liability members. asas thethepreferred liabilityinsurer insurerforforitsits members.
You practice with passion. Our passion protects your practice.
You practice with passion. Our passion protects your practice.
Published on Jan 1, 2009