Central Coast Physicians Fall 2022

MAREENI MAREENI STANISLAUS, MD LYNN FITZGIBBONS, MD

saving the brain

THE 14TH ANNUAL NEUROSCIENCE SYMPOSIUM OF THE CENTRAL COAST DECEMBER 9, 2022 THE HILTON S ANTA BARBARA BEACHFRONT RESORT

Details to follow

Registration required: cottagehealth.org/stb

THIRD

ANNUAL

Cardiology Symposium

Healing the Heart

February 24, 2023

Hilton Santa Barbara Beachfront Resort

Virtual tickets will also be available

This symposium is intended for cardiologists, cardiac surgeons, cardiology fellows and interns, internal medicine and primary care physicians, hospitalists, PAs and NPs, nursing and cardiology technologists in addition to healthcare professionals involved in direct patient care.

More details to follow.

Registration required: cottagehealth.org/hth

New Advanced Technology to Detect Bladder Cancer

Tenet Health Central Coast Sierra Vista Regional Medical Center now offers Blue Light Cystoscopy with Cysview®, an advanced technology for detecting bladder tumors that are too small to find with standard cystoscopy. If you know or suspect that a patient has bladder cancer, Cysview is a minimally invasive procedure that can detect bladder cancer cells. Benefits include:

■ Better inspection of the bladder for cancer, especially small or flat tumors

■ Better removal of bladder tumors when they are first discovered

■ Fewer recurrences of bladder cancer

■ Improved information for planning future care for bladder cancer

Sierra Vista Regional Medical Center is the only healthcare organization in San Luis Obispo County to offer Blue Light Cystoscopy with Cysview. Scan code to learn more.

SIGN UP AT www.cmadocs.org/join

A NEW NORMAL

Reflecting on 2022, it feels like we are in yet another new normal. During the year, we’ve had to cancel some in-person events when COVID cases spiked, and we held many Zoom events, mostly educational workshops. Fortunately, we were able to hold our Annual Membership Celebrations in person for the first time since 2019. In the spring we honored our 2021 Physicians of the Year, Dr. Thomas Hale in San Luis Obispo and Dr. Alex Koper in Santa Barbara County. Recently, we honored our 2022 Physicians of the Year, Dr. Mareeni Stanislaus in San Luis Obispo County and Dr. Lynn Fitzgibbons in Santa Barbara County.

PRESIDENT Samira Kayumi-Rashti, MD

PRESIDENT ELECT Julie Fallon, MD

TREASURER Douglas Murphy, MD

SECRETARY Todd Engstrom, MD

IMMEDIATE PAST PRESIDENT Priti Gagneja, MD

DIRECTORS Eric Amador, MD; Kevin Casey, MD; Michael DiBiase, MD; Jeffrey Gauvin, MD; Jennifer Hone, MD; Bindu Kamal, MD; Rachel May, MD; Rahim Raoufi, MD

CHIEF EXECUTIVE OFFICER Dana Goba, MBA

CMA HOUSE OF DELEGATES

DANA GOBA

At our in-person events, everyone expressed their joy at seeing their colleagues again. There was much laughter, sharing of pandemic stories, and a realization that we got through this together while many were lost around us.

I am optimistic as we plan for the next year, which will include more in-person events. I look forward to continuing the process of moving forward and navigating this new normal together. We will continue listening to our physician leaders and cancel in-person events if needed. I will also gladly roll up my sleeve as recommended to receive boosters and my flu shot to protect myself and those around me.

Wishing our healthcare community a happy holidays, and I will see you in 2023!

Sincerely,

Dana Goba Chief Executive Officer Central Coast Medical Association

REPRESENTATIVES

Sharon Basham, MD; Edward Bentley, MD; Kevin Casey, MD; David Dodson, MD; Julie Fallon, MD; Priti Gagneja, MD; Jennifer Hone, MD; Samira Kayumi-Rashti, MD; Christopher Lumsdaine, MD; Douglas Murphy, MD; Grace Park, MD; Joseph Schwartz, MD

CMA DISTRICT V TRUSTEE Rene’ Bravo, MD

CENTRAL COAST PHYSICIANS MAGAZINE

EDITOR Samira Kayumi-Rashti, MD MANAGING EDITOR Dana Goba, MBA

CREATIVE DIRECTOR Sherry Lavone Design

CONTRIBUTING WRITERS California Medical Association; Kevin Casey, MD; CenCal Health; Savie Health; Debra Kane Hill, MBA, RN; Tenet Health

CONTRIBUTING PHOTOGRAPHERS

California Medical Association, CenCal Health, Savie Health, Tenet Health Central Coast

SUGGESTIONS, story ideas, or completed stories written by current Central Coast Medical Association members are welcome. Opinions expressed by authors are their own and not necessarily those of the CCMA. CCMA reserves the right to edit all contributions for clarity and length as well as to reject any material submitted.

PLEASE DIRECT EDITORIAL INQUIRIES AND SUBMISSIONS TO: Central Coast Physicians

100 N Hope Ave, Ste 14 Santa Barbara, CA 93110

T 805.683.5333 • F 805.364.5431

E magazine@ccmahealth.org

ADVERTISING rates and information sent upon request. Acceptance of advertising in Central Coast Physicians in no way constitutes approval or endorsement by CCMA of products or services advertised. CCMA reserves the right to reject any advertising. All advertising inquiries can be sent to magazine@ccmahealth.org

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1st Capital Bank Provides SBA Financing for Physicians.

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Dispensing Sample Medications: Patient Safety Strategies

DEBRA KANE HILL, MBA, RN, SENIOR PATIENT SAFETY RISK MANAGER, THE DOCTORS COMPANY

RISK TIP

Dispensing free sample medications to patients is commonplace in medical and dental offices. With safeguards in place, it can contribute to improved clinical results and generate goodwill between the practitioner and the patient.

Free sample medications are convenient for patients— particularly those who lack financial or transportation resources—and can improve timeliness and compliance with medication regimens. Sample medications also allow patients to try new and sometimes costly prescriptions on a trial basis to determine if they are effective and without unwanted side effects.

Patient Safety Strategies

Sample medications must be handled with the same level of accountability and security as other prescription medications—as required by the standard of care, federal and state pharmaceutical laws and regulations, and accrediting organizations. Practitioners have the same duty of care to

patients receiving sample medications as they have to patients receiving prescriptions.

Consider implementing the following safety guidelines for drug samples in your practice: Practice Policies and Procedures

• Develop detailed policies and procedures that address sample medication inventory, storage, access, tracking, documentation, and patient care management.

Drug Storage and Access

• Store, secure, and track samples to prevent inappropriate access and loss.

• Allow only designated clinicians and staff to access the drug closet.

• Group medications by drug type when setting up a sample medication closet. Never store sample medications in alphabetical order or next to drugs that have look-alike and sound-alike (LASA) names. (See the Institute for Safe Medication Practices for a current LASA list at www.ismp.org/recommendations/confused-drug-nameslist.)

• Assign staff to monitor and document safe storage per manufacturers’ recommendations and to check medications for expiration.

• Follow state and federal guidelines for disposing of expired medications. Maintain logs in administrative files.

Drug Dispensing

• Never allow staff to provide samples to anyone without provider orders, provider supervision, and patient record documentation. Give sample medications only when prescribed by a licensed provider with prescriptive authority.

• Label samples with prescribing information as required by law.

Patient Record Documentation

• Document any dispensed samples in the patient record. Include the name of the drug, strength, lot number, manufacturer, instructions provided, and discussion of potential side effects.

• Provide written patient education regarding the medication, and document in the patient’s record.

• Obtain and document informed consent from the patient when appropriate, e.g., for the type of medication, possible side effects, or the patient’s first use of the medication.

Administrative Logs

• Maintain administrative records to log a sample medication’s receipt into the practice and to track its inventory and access. Creating a separate log for each medication simplifies the tracking process. Include the drug name, dosage, manufacturer, lot number, expiration date, date and quantity received by the practice, and by whom.

• Maintain administrative records to log a sample medication that is dispensed (separate from the patient record). This allows the practice to identify patients in the event a medication is recalled. Creating a separate log for each medication simplifies the tracking process. Include the date dispensed, patient name, drug name, dosage, lot number, expiration date, quantity dispensed, and by whom.

• Establish a system for identifying and managing drug recalls. (For more information, see the FDA drug recall guidance at www.fda.gov/drugs/drug-safety-andavailability/drug-recalls.)

• Assign administrative staff to review logs routinely for any inconsistencies.

Creating a system for dispensing sample medications can be a significant undertaking, but it provides many benefits for the practice and the patient. For assistance with implementing sample medication safeguards in your practice, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or www.thedoctors.com/contactUs/patient-safetyrisk-management-assistance.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

To find out more about what differentiates The Doctors Company from other medical malpractice insurance carriers as a physicianfirst insurer, contact Matt Lawrence at 310.492.4845 or mlawrence@ thedoctors.com. CCMA members receive additional savings!

Tenet Health Central Coast’s Latest Advancement

in Cancer

Gynecologic Oncology

Care:

THCC Program Integrates State-of-the-Art Tech and Holistic Methodologies

In addition to being the only health system in San Luis Obispo County to fight cancer with the advanced technological tools of Savi-SCOUT, Blue Light Cystoscopy and Robotic Bronchoscopy, Tenet Health Central Coast is proud to announce the launch of its Gynecological Oncology Program.

“A lot of people ask if it’s more gynecological or more

oncological, and the reality is – when it comes to these cancers – is that they are inseparable,” said Dr. Steven Vasilev, who directs the Gynecological Oncology Program for Tenet Health Central Coast Primary & Specialty Care. “This is a separate, board certified specialty and is really the ‘quarterback’ of coordinating care for patients that often have complex and daunting challenges.”

The state-of-the-art program features integrative approaches, which includes using Tenet Health Central Coast’s da Vinci Surgery System. In addition to precision and providing surgeons 3D high-definition views of the surgery area that are 10 times what the human eye could see without the da Vinci system, benefits of this type of surgery include:

• Less pain and blood loss during and after surgery.

• Quicker return to day-to-day activities.

• Shorter hospital stays.

• Less scarring.

• Fewer complications.

Dr. Vasilev calls it, “higher tech for a kinder, gentler surgery,” which is really the goal so patients have the rest and strength to keep fighting the disease, which may include other components, such as chemotherapy.

An important aspect to THCC’s Gynecological Oncology Program is the integration of telemedicine, which has tremendous advantages that include overcoming travel challenges for weakened patients for both medical appointments and counseling, plus it makes it easier for families to participate in supporting the patient.

And what about holistic integrative health techniques?

“The reality is that some 80% of patients are doing some form of holistic treatment, to try to give themselves that extra help, whether it’s perceived or real. But often they won’t tell their doctor because they are afraid their physician won’t understand or approve,” said Dr. Vasilev, who is board certified in each of gynecology, gynecologic oncology, and natural & holistic integrative health – which is rare, if not singular, in the United States. “These patients could end up going to someone who suggests things that interfere with the proven therapies that are part of the patient’s healing plan. So I have always integrated holistic healing to be included in the programs I have built.”

Along with his vast experience in the field, Dr. Vasilev is a Professor and Chairman at Gynecologic Oncology Research Saint John’s Cancer Research Institute (formerly John Wayne Cancer Institute), a professor of Gynecologic Oncology at Loma Linda University School of Medicine and has been named to the “Southern California Super Doctors” by the independent research group MSP Communications.

“It’s really a labor of love. When you bring expert physicians to a program that truly care about their patients as individuals and are able to direct a patient all the way through the process, you end up building more than a program – you have a community of people who really appreciate life and caring for one another.”

Truly, a Community Built on Care.

Annual Membership Celebration

On September 29,

community physicians gathered for our Annual Membership Celebration. At the event, Dr. Edmund Wroblewski presented Dr. Lynn Fitzgibbons with our 2022 Physician of the Year award for Santa Barbara County. The program concluded with CMA president-elect Dr. Donaldo Hernandez providing the keynote address.

Annual Membership Celebration

On September 30, community physicians gathered for our Annual Membership Celebration. At the event, Drs. David Bolivar, Justin Davis, Shan Thomas, and Elizabeth Vogler presented Dr. Mareeni Stanislaus with our 2022 Physician of the Year award for San Luis Obispo County. The program concluded with CMA president-elect Dr. Donaldo Hernandez providing the keynote address.

PHYS I C IANS OF TH E YEAR 22

San Luis Obispo County: Mareeni Stanislaus, MD

Dr. Stanislaus was born in Sri Lanka and went to school first in London and then Honolulu, where she graduated from the prestigious Punahou High School, which is President Obama’s alma mater. She received a Bachelor of Science in Biology and a Bachelor of Arts in Classical Studies from Stanford University before going on to University of California, San Diego for her Doctor of Medicine degree. She then completed her internship and residency at the University of Pennsylvania. Dr. Stanislaus was among the first female OB/ GYN to serve the Central Coast when she began practicing here in 1996, and she opened her own clinic in Templeton in 2017.

Drs. David Bolivar, Justin Davis, Shan Thomas, and Elizabeth Vogler presented Dr. Stanislaus with the award at the Central Coast Medical Association’s Annual Membership Celebration, which happened to occur on her birthday. In addition, Mark Lisa, CEO of Tenet Health Central Coast, provided a video statement that thanked Dr. Stanislaus for her decades of service to the Central Coast and congratulated her on receiving this honor. Dr. Stanislaus was described as family oriented and that she also treats her patients like they are family. >>

Besides enjoying spending time with her three children, two Newfoundland dogs, and two rabbits, Dr. Stanislaus takes pleasure in working at her family’s winery. Dr. Stanislaus and her husband, Ishka, started a vineyard in Paso Robles called Guyomar, which is named after Dr. Stanislaus’ father, and their first wine was released in 2013.

When accepting the award, Dr. Stanislaus said she was overwhelmed by the outpouring of love and respect during the event. She thanked her colleagues, co-workers, friends, and family for supporting her and being instrumental in her career.

Past Physician of the Year Honorees for San Luis Obispo County

2021 Thomas W. Hale, MD

2020 Penny E. Borenstein, MD, MPH 2019 Stephen R Holtzman, MD, MS

2018 Joseph A. Schwartz, MD 2017 Rene’ Bravo, MD 2016 Mark Soll, MD

2015 Fred S. Vernacchia, MD

See you next fall when we honor our 2023 Physicians of the Year in San Luis Obispo and Santa Barbara!

The Central Coast Medical Association honors physicians who have worked to improve the quality of health care, contributed to the education of other physicians, and engaged in community service and other activities outside of medicine.

PHYS I C IANS OF TH E YEAR 22

She now is the program director of the internal medicine residency program at Santa Barbara Cottage Hospital and is the Infectious Disease physician at the Santa Barbara County Public Health Department, where she was previously Deputy Health Officer. She is also the Medical Director of the Cottage Center for Population Health, serves on the Cottage Health Institutional Review Board, and is on the board of the Santa Barbara Neighborhood Clinics.>>

Santa Barbara County: Lynn Fitzgibbons, MD

Dr. Fitzgibbons was born in Fiji and spent her younger years in Scottland before moving to the United States. She went to University of California, Santa Barbara where she was an All-American polo player and earned her Bachelor of Science in Chemistry. Dr. Fitzgibbons then received her Doctor in Medicine from University of California San Diego School of Medicine. She came back to the area for her Internship and Residency with Santa Barbara Cottage Hospital where she was one of the early clinicians with Doctors without Walls. She then served as a volunteer in Uganda treating HIV patients before going to Oregon Health & Science University for her Fellowship in infectious disease.

Dr. Fitzgibbons is also an adjunct professor at UCSB where she teaches classes on STD and drug epidemics from a spatial and geographic lens. In addition, she holds an academic appointment with USC Keck School of Medicine. During the COVID-19 epidemic, she worked closely with the Santa Barbara County Public Health Department and the leadership at Cottage Health on many aspects of the clinical and public health response, with an emphasis on education, clinical care, and policy work.

When presenting the award at the Central Coast Medical Association’s Annual Membership Celebration, Dr. Edmund Wroblewski stated, “Dr. Fitzgibbons has made a better life for many people in our community.” Dr. Fitzgibbons, who ran a trail ultra-marathon in Mammoth Lake the weekend before the event, was unable to attend since she tested positive for COVID the night before. She recorded an acceptance speech the next morning and thanked her family and colleagues for their support and hard work during the pandemic. Dr. Fitzgibbons also gave attendees a call to action to remain connected to each other in the community, which is the secret sauce that helped everyone get through these past few years.

Honorees for

CenCal Health

NEWS HUB:

CALAIM ARRIVES IN SANTA BARBARA AND SAN LUIS OBISPO COUNTIES

What is CalAIM and how does it affect patients and providers on the Central Coast?

The California Advancing and Innovating Medi-Cal program – known as CalAIM – is the far-reaching, multiyear plan to transform Medi-Cal. T he long-term mission of CalAIM is to offer 14+ million Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory. CalAIM will provide expanded services that go beyond traditional medical care, addressing social factors that affect human health from birth to end of life,

including homelessness, behavioral health, care of older adults, services for individuals transitioning from incarceration, and beyond. The comprehensive program was developed by the State of California’s Department of Health Care Services (DHCS). CalAIM is the State’s largest overhaul of how MediCal services are delivered and paid since the implementation of managed care in the late 1970s.

“Our community partners have continuously been at the forefront of innovation, providing person-centered care to our members and underserved neighbors,” said CenCal Health

More information about CalAIM on the Central Coast is available at www.cencalhealth. org/calaim. Additional information about CalAIM can be found on the DHCS site at www.dhcs.ca.gov/CalAIM

CEO Marina Owen. “With the opportunities afforded by CalAIM, we are pleased to support our providers’ efforts to enhance, expand, and strengthen local services.”

CenCal Health, the Medi-Cal health plan for Santa Barbara and San Luis Obispo counties, has implemented two new initiatives under the CalAIM framework. They are:

• Enhanced Care Management (ECM) is a benefit for members with complex needs requiring seamless coordination between multiple doctors and other care providers. With ECM, enrolled members are assigned a lead care manager who helps coordinate doctors, specialists, pharmacists, case managers, and social service providers, among others, in order to comprehensively manage a member’s primary care, acute care, behavioral health, developmental health, oral health, and community services and supports.

• Community Supports provides medically appropriate and cost-effective alternatives to traditional medical services. Community Supports comprehensively addresses the needs of members — including those with the most complex challenges affecting health such as homelessness, unstable and unsafe housing, food insecurity, and/or other social needs.

CenCal Health currently offers two Community Supports –Medically-Tailored Meals and Recuperative Care. Medically Tailored Meals provides meals to members with diabetes,

congestive heart failure, or chronic kidney disease, and who have had a skilled nursing facility stay, inpatient hospital visit, or emergency room visit within six months.

Recuperative Care is medically-supervised respite care for patients who have just been released from the hospital due to serious illness or injury, and are experiencing homelessness or at risk of homelessness. Community partners, shelters, and local hospital providers Dignity Health, Cottage Health and Tenet Health have been offering Recuperative Care since 2019. Through CalAIM, CenCal Health will continue to support these critical services.

“We are addressing homelessness among the most vulnerable individuals in the community,” said Dr. Lynn Fitzgibbons, Cottage Health’s Medical Director of Population Health. “The Cottage Recuperative Care Program at PATH is dedicated to helping those experiencing homelessness access vital services to address their medical needs, improve their health, and transition to stable housing.”

Good Samaritan Shelter, PATH Santa Barbara, and Community Action Partnership of San Luis Obispo partner with the area hospitals to ensure an integrated referral and care coordination structure for members moving in and out of respite services. “Ending homelessness for individuals, families and communities requires partnerships across many sectors, including healthcare,” said Jennifer Hark Dietz, CEO of PATH. “That is why, at our Santa Barbara interim housing site, we provide people experiencing homelessness with access to services they need to improve their health, increase their income, and transition to stable housing.”

Julie Fallon, MD President Internal Medicine Templeton

Douglas Murphy, MD President-Elect Psychiatry San Luis Obispo

Todd Engstrom, MD Treasurer

Internal Medicine Santa Barbara

2023 CCMA BOARD OFFICERS

Rachel May, MD Secretary Emergency Medicine San Luis Obispo

Samira Kayumi-Rashti, MD

Immediate Past President Pediatrics Santa Barbara

2023 CCMA BOARD DIRECTORS

Kevin Casey, MD Vascular Surgery Santa Barbara

Michael DiBiase, MD Nephrology San Luis Obispo

Priti Gagneja, MD Internal Medicine Santa Barbara

Jennifer Hone, MD Endocrinology Santa Barbara

Bindu Kamal, MD Nephrology Santa Barbara

Christopher Quijano, DO General Surgery Santa Barbara

Rahim Raoufi, MD Gastroenterology Lompoc

Daniel Roshan, MD Pain Medicine Santa Barbara

California’s Big Move on Data Exchange

With a combination of mandates, a new governing board, and publicly funded assistance, the California Data Exchange Framework (DxF) is set to pull health information exchange into the 21st Century.

WITH A COMBINATION OF MANDATES, A NEW GOVERNING BOARD, AND PUBLICLY FUNDED ASSISTANCE, THE CALIFORNIA DATA EXCHANGE FRAMEWORK (DXF) IS SET TO PULL HEALTH INFORMATION EXCHANGE INTO THE 21ST CENTURY.

Probably every physician practice has had the frustrating experience of trying to deliver the best possible care to a patient, only to be hampered by the inability to access relevant health information. Important pieces of a patient’s history, such as prescriptions, chronic conditions, or previous diagnoses may be trapped in data silos held in a million different places, inaccessible to the patient or the physician at the point of care. Myriad studies of the health care system have shown that lack of health information at the point of care often leads to duplication, waste, and delay.

Despite the widespread adoption of electronic health records (EHRs) across the state, this problem persists. A combination

of technology challenges, competitive forces, and some legal uncertainty has kept data locked away from both patients and physicians.

Starting in 2020, the federal government began working to address this problem through the 21st Century Cures Act Final Rule, often known as the “Information Blocking Rule.” This rule clarified in federal regulation that patients have the right to access their own medical information through the technology of their choosing. For the first time, physicians, hospitals, and health plans must make that information available. This rule started the country down the path of widespread and seamless data exchange.

Now, the California Medical Association (CMA), is working with the State of California to build on the federal regulations to accelerate and expand data exchange efforts here in the state. After a year of legislative negotiations, State Budget appropriations, and stakeholder meetings, the California Health and Human Services Agency (CHHS) on July 5, 2022, published the Data Exchange Framework.

The Data Exchange Framework, usually abbreviated “DxF”, will require all actors in the health care system – physicians, hospitals, health plans, skilled nursing facilities, etc. – to make patient data available to all other actors within the bounds of federal and state privacy laws. It will do this by requiring all those actors to sign the Single Data Sharing Agreement (described below). Once they have signed the agreement, practices and others will be contractually obligated to share data across the health care system.

Importantly, the Data Exchange Framework does not require practices to utilize any particular data sharing technology. The state is not building a “Statewide HIE.” When the law that created the framework was being written, CMA’s position was that physicians should have the flexibility to choose the technology that works best for their practice. Based on CMA’s advocacy, the law prohibits the state from forcing physicians into one system.

available to other signatories of the Data Sharing Agreement. The date by which practices must comply with this requirement depends on the size of the practice. In general, practices of more than 25 physicians will need to be engaged in data exchange by January 31, 2024. Practices smaller than 25 physicians will have 2 additional years, until January 31, 2026.

2. SINGLE DATA SHARING AGREEMENT

WHEN THE LAW THAT CREATED THE FRAMEWORK WAS BEING WRITTEN, CMA’S POSITION WAS THAT PHYSICIANS SHOULD HAVE THE FLEXIBILITY TO CHOOSE THE TECHNOLOGY THAT WORKS BEST FOR THEIR PRACTICE. BASED ON CMA’S ADVOCACY, THE LAW PROHIBITS THE STATE FROM FORCING PHYSICIANS INTO ONE SYSTEM.

To govern the Framework, the state has created the Single Data Sharing Agreement (DSA). This document is a contract that all practices are required by law to execute by January 31, 2023. The intent of the DSA is to act as a contract between physician practices, hospitals, health plans, etc., that they will make data available to each other upon request. The DSA lays out the parameters of how that data exchange should happen, predominantly via accompanying Policies and Procedures that describe what data elements need to be exchanged, privacy and security standards, and permitted uses of health data. The DSA also lays out practices’ responsibility to comply with the HHS Data Exchange Board (see below).

3. HHS DATA EXCHANGE BOARD

Instead, the Framework is intended to be “technology agnostic,” meaning that practices are free to choose the method of data exchange that works best for them. This could include a local health information organization, a national data sharing network, or other data sharing technology.

Now that the Framework has been published, the timeline for implementation is going to move quickly. It will be important for practices to familiarize themselves with the requirements of the Framework and begin their preparations as soon as possible. To help practices prepare, this article will give a high-level overview of the Framework, describe some things practices can do to prepare, and point them to some helpful resources CMA is developing.

The Data Exchange Framework

The Data Exchange Framework consists of four major components:

1. DATA SHARING REQUIREMENT

As described above, the Framework includes a legal requirement that physician practices and other health care entities make data

The State has proposed to create a 5-to-7-member governing body that will oversee data exchange in California. This board will be charged with overseeing and updating the Data Sharing Agreement, ensuring compliance with the DxF, and qualifying health information organizations. The details about this board will be included in a legislative proposal that will be introduced next year.

4.

TECHNICAL ASSISTANCE FOR SMALL AND SAFETY NET PRACTICES

The 2022-23 State Budget included $50 million for providing technical assistance to small practices and other safety net providers. As of the writing of this article, there are no additional details to share. CMA is actively engaged in ensuring that the funding will reach physician practices quickly and efficiently, to help them prepare for the DxF.

For more details on these components, CMA members can access the CMA DxF Fact Sheet on the CMA website.

Timeline

A GENERAL TIMELINE FOR THE DATA EXCHANGE FRAMEWORK IS LISTED IN THE TABLE BELOW:

DATE REQUIREMENT

JULY 5, 2022 + CHHS PUBLISHED THE FINAL DATA EXCHANGE FRAMEWORK

FIRST QUARTER 2023 + THE GOVERNANCE ENTITY (SEE ABOVE) BEGINS THEIR WORK

JANUARY 31, 2023 + ALL HEALTH AND HUMAN SERVICES ORGANIZATIONS (INCLUDING PHYSICIAN PRACTICES) MUST EXECUTE THE DATA SHARING AGREEMENT

JANUARY 31, 2024 + MOST HEALTH CARE PROVIDERS (SEE TABLE BELOW) MUST IMPLEMENT THE DATA EXCHANGE FRAMEWORK

JANUARY 31, 2026 + SMALL AND SAFETY NET PRACTICES (SEE ABOVE) MUST IMPLEMENT THE DATA EXCHANGE FRAMEWORK

As you can see, practices are required to execute (sign) the Data Sharing Agreement in just a little over five months from the writing of this article. The state has not yet announced how that process will take place, so please watch for further announcements from CMA or the State of California. In addition, it is important for physicians to know that you must sign the agreement by January 31, 2023, even if your practice is small enough to be in the cohort that does not have to comply until 2026.

What Practices Can Do Now

With these new requirements coming down over the next four years, practices will want to get started on building their game plan for compliance as soon as possible.

If you participate in a medical group or an IPA, a good place to start is by contacting that entity to inquire about their plans for compliance with the Data Exchange Framework. If you get access to an EHR system or population health platform through the group or IPA, and they already engage in data exchange, an individual practice may not need to sign their own DSA.

The organization will sign the Data Sharing Agreement on your behalf, and data exchange will be handled at that level.

For more independent practices, now is a good time to familiarize yourself with the health information organizations (HIOs) that serve your community. Members of the California Association of Health Information Exchange (www.ca-hie. org/about/members/) represent the largest and most well-

established HIOs in the state. They have already signed an agreement to work together. As more entities become aware of the requirements of the DxF, lead times to sign up with an HIO may become longer; it will help to approach them soon.

Finally, be sure to work with your EHR vendor, especially if you work with a smaller, specialty system. These systems can require custom interfaces to onboard to an HIO, which can be both time-consuming and costly. On the plus side, some EHRs connect through a national data sharing network, allowing you to comply without adding a new vendor. Either way, it helps to include your EHR vendor early and often.

CMA is Here to Help

To help practices get ready for the DxF, CMA is developing resources as quickly as information becomes available.

On June 28, 2022, CMA held an online briefing on the Data Exchange Framework. A recording of the briefing is available on the CMA YouTube Channel (www.youtube.com/c/CMAdocs).

In addition, CMA has published a Fact Sheet that is available to all physician members on the CMA website (www.cmadocs. org and search “data exchange framework”). The Fact Sheet summarizes the requirements and components of the DxF and includes a Frequently Asked Questions document that will be updated regularly as more information becomes available.

Finally, CMA members can always call the CMA Member Helpline at 800-786-4262 for assistance.

Anthrax (Human or Animal)

Botulism (Infant, Foodborne, Wound, Other)

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Hepatitis E, Acute Infection

Human Immunodeficiency Virus (HIV), acute

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Brucellosis (Human)

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Campylobacteriosis Infection, progression to stage 3 (AIDS)

Candida auris, colonization or infection

Influenza (Death Lab Confirmed 0 17 yrs old)

Influenza due to novel strains (human)

Shigellosis

Smallpox (Variola)

Syphilis (all stages, including congenital)

Tetanus

Trichinosis

Tuberculosis

Tularemia (Animal)

Tularemia (Human)

Typhoid Fever, Cases and Carriers

Vibrio Infections deaths)

Chicken Pox (outbreaks, hospitalization,

Chikungunya Virus Infection

Cholera

Cyclosporiasis

Cysticercosis or Taeniasis

Dengue Virus Infection

Diphtheria

Leprosy (Hansen’s Disease)

Viral Hemorrhagic Fevers Human/Animal (e.g.,

Leptospirosis Crimean Congo, Ebola, Lassa and Marburg

Listeriosis viruses)

West Nile Virus (WNV) Infection

Yellow Fever

Meningitis, Specify Etiology: Viral, Bacterial,

Middle East Respiratory Syndrome (MERS) Local Surveillance

Monkeypox or orthopox virus infections

Vaping-Associated Pulmonary Injury (VAPI) /

Mumps E cigarette, or Vaping, Product Use Associated

Novel Virus Infection with Pandemic Potential Lung Injury (EVALI)

Paralytic Shellfish Poisoning

Domoic Acid Poisoning (Amnesic Shellfish

Ehrlichiosis

Paratyphoid Fever

TST Reactors (age <3 years only) Poisoning)

Pertussis (Whooping Cough)

Plague, Human or Animal

OCCURRENCE OF ANY UNUSUAL DISEASE

Encephalitis, Specify Etiology: Viral,

Poliovirus Infection Bacterial, Fungal, Parasitic

Psittacosis

OUTBREAKS OF ANY DISEASE

Q Fever (Including diseases not listed in §2500. Specify (STEC) including E. coli O157

Escherichia coli: shiga toxin producing

Flavivirus Infection of undetermined species

Rabies, Human or Animal Institutional and/or open Community)

Relapsing Fever

Respiratory syncytial virus associated deaths (2 or more cases from separate households In laboratory confirmed cases less than five with same suspected source) years of age

Foodborne Disease:

Giardiasis

Rickettsial Disease (non-Rocky Mountain

Gonococcal Infections Spotted Fever, including Typhus and Typhus

Haemophilus influenzae, invasive disease like Illnesses) HIV/AIDS Surveillance Program (<5 years only)

Hantavirus Infections

Hemolytic Uremic Syndrome

Hepatitis A (Acute infection)

Hepatitis B (specify acute, chronic, or perinatal)

Rocky Mountain Spotted Fever Phone: (805) 681 4750 / 805 346 8444

Rubella (German Measles)

Rubella Syndrome, Congenital

Salmonellosis (Other than Typhoid Fever)

Scombroid Fish Poisoning

Shiga toxin (detected in feces) California Code of Regulations, title 17, sections 2500(b) and 2500(j) are temporarily modified to eliminate the requirements for health care providers to report COVID 19 cases, except as follows: a. Within one working day of identification of hospitalization and/or death of a patient due to COVID 19, health care providers shall report this information.

Hepatitis C (specify acute, chronic, or perinatal)

b. The reporting of hospitalizations and deaths by healthcare providers required by subparagraph a. is in addition to weekly reporting of hospitalized COVID 19 cases by hospitals as required under AFL 21 25.[3]

c. Health care providers conducting point of care testing must still report test results consistent with the requirements for laboratories.

REPORTABLE NON COMMUNICABLE DISEASES AND CONDITIONS

Conditions Impairing Driving Capacity (pursuant to H&S 103900) Lapses of consciousness or control. Alzheimer’s disease or other conditions which may impair the ability to operate a motor vehicle safely. It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected case of any of the diseases or conditions listed above, to report to the local health officer for the jurisdiction where the patient resides. Where no health care provider is in attendance, any individual having knowledge of a person who is suspected to be suffering from one of the diseases or conditions listed below may make such a report. "Health care provider" encompasses physicians, surgeons, veterinarians, podiatrists, nurse practitioners, physician assistants, registered nurses, nurse midwives, school nurses, infection control practitioners, medical examiners, coroners, dentists and chiropractors.

San Luis Obispo County Public Health Department www.slopublichealth.org

Reportable Diseases and Conditions

Required under Title 17, California Code of Regulations (CCR) §2500

Phone: 805 781 5500  Address: 2191 Johnson Avenue, SLO, CA 93401  Fax: 805 781 5543

 Hepatitis C (specify acute case or chronic) Hepatitis D (Delta specify acute case or chronic)  Hepatitis E, acute infection Human Immunodeficiency Virus, acute▴  Human Immunodeficiency Virus (HIV), any stage ▴  Human Immunodeficiency Virus (HIV), progression to stage 3 (AIDS)▴  Influenza deaths in laboratory confirmed cases (<18 years of age)  Influenza due to novel strains (human)

 Rickettsial Diseases (non‐Rocky Mountain Spotted Fever,including Typhus and Typhus‐like illnesses)

Rocky Mountain Spotted Fever

Rubella (German Measles)  Rubella syndrome, congenital

Salmonellosis (other than Typhoid Fever) Scombroid Fish Poisoning  Shiga toxin (detected in feces)  Shigellosis  Smallpox (Variola) Syphilis (all stages, including congenital)

Cryptosporidiosis

Cyclosporiasis Cysticercosis or Taeniasis  Dengue Virus Infection

Diphtheria Domoic Acid Poisoning (Amnesic Shellfish Poisoning) Ehrlichiosis  Encephalitis specify etiology (Viral, Bacterial, Fungal, Parasitic)  Escherichia coli: shiga toxin producing (STEC) including E. coli O157  Flavivirus infection of undetermined species  Foodborne disease (2 or more cases from separate households with same suspected source) Giardiasis Gonococcal infections  Haemophilus influenzae, invasive disease ( <5 years of age) Hantavirus infections Hemolytic Uremic Syndrome  Hepatitis A, acute infection  Hepatitis B (specify acute case or chronic)

 Legionellosis  Leprosy (Hansen’s Disease)  Leptospirosis Listeriosis  Lyme Disease Malaria Measles (Rubeola) Meningitis specify etiology (Viral, Bacterial, Fungal, Parasitic) Meningococcal infections Middle East Respiratory Syndrome (MERS) Monkeypox or orthopox virus infections  Mumps  Novel Virus Infection with Pandemic Potential Paralytic Shellfish Poisoning Paratyphoid Fever Pertussis (Whooping Cough)  Plague, human or animal Pneumococcal disease, invasive, 0‐18 years old (at the request of the local health officer) Poliovirus Infection Psittacosis Q Fever  Rabies, human or animal Relapsing Fever  Respiratory Syncytial Virus associated deaths in laboratory confirmed cases (<5 years of age)

Tetanus Trichinosis  Tuberculosis Tularemia, animal

Tularemia, human

Report the following diseases/condition s, including suspected cases, to CalREDIE Provider Portal at https://calredie.cdph.ca.gov AND the following:  = Report immediately by telephone.  = Report within one (1) working day of identification.  = Report within 7 calendar days from the time of identification. Anaplasmosis  Anthrax (human or animal)  Babesiosis Botulism (Infant, Foodborne, Wound, Other) Brucellosis (Animal except B. canis) Brucellosis (human)  Campylobacteriosis  Candida auris, colonization or infection  Chancroid  Chickenpox (outbreaks, hospitalizations and deaths)  Chikungunya Virus Infection Cholera Ciguatera Fish Poisoning Coccidioidomycosis Creutzfeldt‐Jakob Disease (CJD) and other Transmissible Spongiform Encephalopathies (TSE)

Typhoid Fever, cases and carriers

Vibrio infections

Viral Hemorrhagic Fevers, human or animal (e.g., Crimean‐Congo, Ebola, Lassa, and Marburg viruses)

West Nile Virus (WNV) infection

Yellow Fever

Yersiniosis

Zika Virus Infection Outbreaks of any disease (including diseases not listed in §2500). Specify institutional and/or open community.  Occurrence of any unusual disease Local Surveillance  Cannabis related illness  TST reactors (age <3 years only)  Vaping associated illness ▴

HIV Reporting: DO NOT FAX REPORTS. HIV infection is reportable by traceable mail or person‐to‐person transfer within seven (7) calendar days by completion of the HIV/AIDS Case Report Form (CDPH 8641A). For HIV‐specific reporting requirements, see Title 17, CCR, §2641.5‐2643.2

Reportable Non‐Communicable Diseases/Conditions: Disorders characterized by lapses of consciousness (§2800 2812),Alzheimer’s Disease, or other conditions that may impair the ability to operate a motor vehicle safely (H&SC 103900); Pesticide‐related illness or injury (known or suspected cases; H&SC 105200); Cancer (H&SC 10387), including benign and borderline brain tumors (except 1)basal and squamous skin cancer unless occurring on genitalia, and 2)carcinoma in situ and CIN III of the cervix §2593)

Medical Scribes

Do They Help Prevent Burnout?

By Kevin Casey, MD

I remember when I first heard about having a medical scribe after I moved to Santa Barbara and joined my former practice. It sounded so bizarre and foreign to me. I reached out to several colleagues to see if they had ever heard of this with varying responses. I even read an online review of a physician in the group, stating “there was a person on the computer who followed the doctor around and said nothing.” The review was negative and claimed that my former partner had poor social skills. That part was true.

Many medical practices have begun implementing scribes in different forms. Scribe America states that “A Medical Scribe is essentially a personal assistant to the physician; performing documentation in the electronic health record (EHR), gathering information for the patient’s visit, and partnering with the physician to deliver the pinnacle of efficient patient care.” Scribes assist in many different departments, from the Emergency Room/Urgent Care setting to hospitalist and outpatient settings. The purpose is to reduce the workload of the physician while maintaining EHR and clinical accuracy throughout the patient encounter.

Over the past five years, and perhaps amplified by the pandemic, I believe that physicians have grown comfortable talking more openly about physician burnout. Both on the CCMA board and within the Cottage medical community, where I serve as Chair of the Department of Surgery, this has become a salient point of discussion. According to a 2021 poll by the American Medical Association, 63% of physicians have experienced at least one symptom of burnout in the prior 12 months. A large number of physicians have considered leaving the practice of medicine altogether in the past 2 years, many citing the significant administrative burden as a main cause. No longer do we talk about burnout in quiet corners or solely with a therapist. Instead, as a community we are openly recognizing that physicians are being pulled in many directions, spread too thin, and this can potentially lead to poor outcomes both for ourselves and our patients.

For me, I frequently see more than 40 patients on an average clinic day. I know internists who may see 4 times this many in a week. Colleagues have shared with me that they are in their office until after 7 pm completing their charting. This is time that could be spent with family, hobbies, or just taking a break from medicine. If I didn’t have a medical scribe to assist me, then I would literally be awake until all hours completing notes and documenting. I am also confident that the accuracy of my notes would be compromised.

Concerns over medical scribes from physicians are “they don’t know what I’m thinking,” “they can’t possibly document everything that I need,” and “I’m nervous about the reliability of the note.”

Each of these are valid concerns. I would argue that working with a scribe is an important relationship. And just like any vital relationship, it requires work and cultivation. I’ve had scribes that I couldn’t work with and had to let go. I also do a fair amount of teaching and explaining to them. I’ve been working with my current scribe (virtually) for over 15 months, and he has come to understand my thought process and how I explain details of procedures to patients and their families, as well as my rationale for my medical decision making. Yet, I still review every single note before signing it. And we will review things together if I feel there are ways to improve the clinical note.

I don’t have to tell any physician that our medical landscape is continually evolving. Unfortunately, physicians are often an afterthought as far as the impact of certain developments (managed care, EHR, etc.). A medical scribe may not fit well for all practices. For me, it has helped tremendously. I’ve even had patients thank me for paying for one, recognizing that the investment allows me to concentrate fully on them, rather than taking notes on a clipboard during our conversation. While it isn’t a golden ticket that solves all of my woes, my scribe certainly has helped me maintain both a better quality of life and commitment to patient care that I’m not sure I’d be able to maintain otherwise.

CLASSIFIEDS

POSITIONS AVAILABLE

Whether you are a seasoned physician or just out of residency, the CALIFORNIA PHYSICIAN CAREER CENTER offers the opportunities and resources you need to advance your career. This benefit includes tips on resume writing, interviews, and networking, as well as hundreds of current job openings in California. Opportunities can be found at https://careers.cmadocs.org.

CENCAL HEALTH is a community-accountable health plan that partners with over 1,500 local physicians, hospitals, and other providers in delivering patient care to more than 200,000 members in Santa Barbara and San Luis Obispo counties. Opportunities can be found at www.cencalhealth.org/workwithus.

COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST is now hiring. CHC is a nonprofit organization operating federally qualified health centers that provide comprehensive care. Since 1978, CHC has grown to over 30 locations serving over 120,000 unique patients annually across San Luis Obispo and northern Santa Barbara counties. We are always looking for skilled, compassionate providers of all levels. See our list of current openings online at: chccares.link/careers - for more details, email mmasatani@chccc.org.

The COUNTY OF SAN LUIS OBISPO is committed to serving the community with pride to enhance the economic, environmental, and social quality of life in San Luis Obispo County. Opportunities can be found at www.slocounty.ca.gov

The COUNTY OF SANTA BARBARA delivers exceptional services so Santa Barbara County’s communities can enjoy a safe, healthy, and prosperous life. Opportunities can be found at www.sbcountyjobs.com

DIGNITY HEALTH is a mission-driven, not-for-profit organization of more than 40 hospitals and care centers across California, Arizona, and Nevada. Opportunities can be found at www.dignityphysiciancareers.org.

PLANNED PARENTHOOD California Central Coast is a dynamic and fulfilling place to work. Our staff is caring, knowledgeable, dedicated and we are committed to a diverse workplace and encourage you to apply. Opportunities can be found at https://jobs.lever.co/ppcentralcoast

SANSUM CLINIC is the largest and oldest multi-specialty group between San Francisco and Los Angeles with over 180 physicians and surgeons and a staff of healthcare professionals in over 30 specialized areas of medicine. Opportunities can be found at www.sansumclinic.org/ physician-provider-job-opportunities.

Whether you are interested in employment, relocating your practice or joining the staff of one of our urgent care centers, TENET HEALTH most likely has an opportunity that’s right for you. Opportunities can be found at www.tenethealth.com/for-physicians/physician-careers.

If you would like to submit a listing to our Classifieds, contact ccma@ccmahealth.org. Listings are free for members with reasonable rates for nonmembers.

Gynecologic Oncology Steven A. Vasilev, MD

Steven Vasilev, MD, FACOG, FACS, FACN, ABOIM is board certified in obstetrics and gynecology, gynecologic oncology and integrative and holistic medicine. Dr. Vasilev earned his medical degree and completed his residency at USC Keck School of Medicine in Los Angeles, CA. He obtained his fellowship in the same institution through its USC Norris Comprehensive Cancer Center. Tenet Health Central Coast is accepting new patients and most major insurance plans. Dr. Vasilev treats a range of gynecologic oncology conditions with:

3 New & Rejoining

The Central Coast Medical Association welcomes the following physicians as members

...and even more on the way.

Catherine Ann Collings, MD, MS Cardiovascular Disease

Templeton

RESIDENTS

Jaclyn DeRieux, MD General Surgery

Santa Barbara Cottage Hospital

Emma Towslee, MD Pediatrics

Santa Barbara Cottage Hospital

Congratulations to our members who have retired

Beverly Joy Sanson Ramos, MD

Psychiatry

Templeton

Savie Health’s physicians are all volunteers. If you are interested in volunteering at Savie Health, or if you would like to learn more about our organization, please contact Executive Director Eryn Shugart at eryn.shugart@saviehealth.org. Se habla español.

A New Community Resource, Savie Health free clinic

There are an estimated 41,000 residents in Santa Barbara County who don’t have health insurance, either because they work part-time, are self-employed and are not eligible for employed sponsored health insurance and can’t afford the cost of Covered California, or because they are undocumented.

Savie Health free clinic recently opened in Lompoc and is our Santa Barbara County’s first free medical clinic for community members without health insurance. Our founder, Dr. Ahmad Nooristani, is a hospitalist at Lompoc Valley Medical Center, and previously founded the SLO NOOR Foundation free clinic in San Luis Obispo. That clinic has had over 40,000 patient encounters since it opened in 2011.

Dr. Nooristani saw a similar need in Lompoc, and Savie Health opened in June of this year. Savie is open weekdays

and on Saturdays, a day that works for many of our patients to be seen, so that they do not have to miss work. Savie pays the costs of patients’ lab and imaging tests including for x-rays and mammograms, provides discounted medication coupons, and works with patients to assess their emotional well-being and social determinants of health. Results from screenings are used by both our physicians, in assessing patients' needs for medication, and also our Licensed Clinical Social Workers, to provide referral to other resources.

Savie Health is available to serve as these patient’s medical home, and to provide ongoing care with the goal of preventing hospitalization and/or death due to diabetes, heart attack, stroke, and other chronic conditions. Savie intends to add dental and vision to its services in early 2023.

In Memoriam

WILLIAM

F

GEBHART, MD

1928-2022

Bill Gebhart, MD passed away on July 7, 2022, at home, with his wife Rosemarie at his side. He was 94 years old.

Bill joined Sansum Clinic on August 1, 1957, in the Internal Medicine Department. He went to the University of Pennsylvania Medical School and Cleveland Clinic. In the mid-1970s, he was one of the original members of the newly created Nephrology Department and was involved in dialysis treatment in Santa Barbara since its inception here. He was involved in the short-lived efforts at kidney transplants in Santa Barbara around that time as well. He was involved in Clinic leadership roles during his last few decades at The Clinic – he was here for more than 40 years – and was one of

the instrumental players in the early 1970s in the creation of the then-novel 1206(l) Medical Foundation model in California.

Santa Barbara Medical Foundation Clinic along with Palo Alto Medical Foundation Clinic and Gould Medical Foundation Clinic were the three original Medical Foundations in the State of California in the early 1970s. Dr. Gebhart and other visionaries at Santa Barbara Medical Clinic with their colleagues at the other two Clinics mentioned above were responsible for creating the legislation that created the 1206 (l) model that now cares for millions of California residents.

Bill remained a practicing internist/nephrologist until his retirement from the Clinic in 1999, 42 years and two months after he started. He was the Assistant Medical Director of the Clinic at the time of his retirement. He was very involved in quality initiatives and JAHCO accreditation at the time of his retirement and went on to work part time as a JAHCO surveyor after his retirement.

He is survived by his wife of 30 years, Rosemarie, and his two children, Judy and Cynthia, as well as his stepchildren, Nicole and Madaline, and two grandchildren.

Adapted from the Santa Barbara Independent

In Memoriam

Tournament.

THOMAS G OCHSNER, MD

1936-2022

Thomas Ochsner, 86, passed peacefully on August 6, 2022, surrounded by his family in his home in Santa Barbara, California.

He was born to Dr. Clarence and Anita Ochsner on February 10, 1936, in Chicago, IL, the second of ten children. He grew up in Wabasha, MN where he attended St. Felix High School. He went on to medical school at the University of Minnesota where he met his wife Kathryn Nitzkowski. Graduating in 1961, he interned at Scripps Memorial Hospital in San Diego and completed his residency at Anchor Hospital in St. Paul, Minnesota as a urologist.

Dr. Ochsner served three years in the Navy at Great Lakes Naval Base at the Naval Hospital in Chicago, IL during the height of the Viet Nam war. He earned the rank of Commander. He moved his family to Santa Barbara, California in 1968 where he spent 61 years in private practice. He was not only known as a skilled surgeon, but more importantly, a kind and compassionate doctor. He was awarded the Lifetime Achievement Award from St. Francis Medical Center, was a board member of the St. Francis Foundation for over 30 years and was key to the success of the St. Francis Celebrity Golf

Thomas was a beloved husband, father, and grandfather with a zest for life that was only outdone by his faith in God. Although, there were times when some of his golf buddies were sure he would have traded them both for an 8-foot birdie putt during one of his weekly rounds at La Cumbre Country Club. He treated everyone he met in life the same, with kindness and respect. He never talked bad of anyone nor ever utter a foul word (really, never!). His gentleness was surprisingly complimented by a strong determination that was not obvious on the surface. He will be greatly missed by many.

Thomas is survived by his wife, Kathryn (Kay); children, Kathryn, Elizabeth, Thomas, Jr., and Andrew; grandchildren, Katie, Amanda, Olivia, Alyx, Lauryn, Thomas, James, Natalie, Drew, Christopher, and Michael; and many greatgrandchildren.

Adapted from the Santa Barbara News-Press