Issuu

SPRING 2021

PHYSICIAN WELLNESS

If not now, when? Free PPE • COVID-19 Malpractice Claims • Information Blocking Rule

state-of-the-art

epilepsy care The Cottage Epilepsy Center (CEC) is the only Center of its kind between Los Angeles and the Bay Area. Our comprehensive epilepsy program includes a team of epilepsy specialists and state-of-the-art monitoring equipment. Each patient will receive personalized care during their diagnosis and treatment. • Video-EEG monitoring for differential

HOW TO REFER A PATIENT: To arrange an appointment for your patient or to comanage/transfer care to the epilepsy center, please contact the office of Dr. Michael Gibbs at:

(805) 682-8153

diagnosis of “spells” and pre-surgical evaluation for medically refractory epilepsy • Imaging techniques including 1.5 and 3.0 Tesla high resolution MRI, PositronEmission Tomography (PET) scanning for localization of seizure foci

If you need more immediate assistance or have questions regarding referring a patient, please call Karen Secore, Nurse Navigator for the Epilepsy Center at:

(805) 832-3633

• Specialized neuropsychological testing • Evaluation for medical and surgical management, which may include resection, and neurostimulator implant procedures such as VNS and RNS

CENTRAL COAST PHYSICIANS

Spring 2021

VOLUME 6, NUMBER 2 • SPRING 2021

10 13 16 24 28 30 35 Spring 2021

{FEATURES} TENET & UCSF PARTNERSHIP

{DEPARTMENTS} 7 PRESIDENT’S MESSAGE

NEW STUDENT HEALTH ED PHYSICIAN HEALTH & WELLNESS COUNCIL NOMINATIONS OPEN FREE PPE DIRECT

14 RISK TIP 26 CENCAL HEALTH NEWS 34 CLASSIFIEDS 36 NEW MEMBERS 38 IN MEMORIAM

FED INFO BLOCKING RULE SHAPE STATEWIDE POLICY

CENTRAL COAST PHYSICIANS

Letter from the CEO

MY VACCINATION EXPERIENCE I have been anxiously waiting to be vaccinated

DANA GOBA

for COVID-19, and I was ecstatic when I learned I was eligible. As I went to the website, I felt like a teenager trying to score concert tickets via Ticket Master. When my husband and I got seats next to each other, I mean the same vaccinations time slot, I was overjoyed.

When the day arrived, I bound up the stairs into the mass vax clinic. Then I heard it. Quiet. I was expecting a party with full fanfare and for everyone to be as excited as me. One woman coordinating the f low of people did little dance with me as she shared my enthusiasm. As I went to the observation area, I hoped for a band, or maybe a DJ, or at least Spotify. Instead, I sat quietly until my 15 minutes had elapsed. Overall, the process was very efficient, everyone was friendly, and it couldn’t have gone any better. So, I played party music on the drive home.

PRESIDENT Priti Gagneja, MD PRESIDENT ELECT Samira Kayumi-Rashti, MD TREASURER Julie Fallon, MD SECRETARY Thomas Hale, MD IMMEDIATE PAST PRESIDENT Kevin Casey, MD DIRECTORS Eric Amador, MD; Michael DiBiase, MD; Todd Engstrom, 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 REPRESENTATIVES Sharon Basham, MD; Edward Bentley, MD; Kevin Casey, MD; David Dodson, 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 Priti Gagneja, MD MANAGING EDITOR Dana Goba, MBA CREATIVE DIRECTOR Sherry Lavone Design CONTRIBUTING WRITERS California Medical Association; CenCal Health; Andrea Estrada; Douglas P. Murphy, MD; Tenet Health Central Coast; Robert E. White Jr.

I feel fortunate my COVID pod were all vaccinated the same week, and we’re planning a celebration for when we’re all fully vaccinated in six weeks. We’re trying to determine what should be on the menu for a vaccination dinner party, and I’ve seen quite a few coronavirus-themed food articles. As soon as we are able, I am looking forward to celebrating in person with you. Physicians have endured so much these past 15 months, and you are to be celebrated. As soon as our incredible health officers say it is safe, we will have an in-person physician social. Until then, if you have any vaccine celebration recipes, let me know. Sincerely,

CONTRIBUTING PHOTOGRAPHERS CenCal Health; Tenet Health Central Coast; University of California, Santa Barbara 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

Dana Goba Chief Executive Officer Central Coast Medical Association

CENTRAL COAST PHYSICIANS

reject any advertising. All advertising inquiries can be sent to magazine@ccmahealth.org. A COMPONENT OF THE

Spring 2021

CENTRAL COAST PHYSICIANS

Virtual Cocktail Making with

Simply Cocktails MAY 27, 2021 | 6:00 PM

Mark Your Calendar! RSVP at ccmahealth.org/events

Virtual

Medicare Workshop

Medicare 2022 in Review

SEPTEMBER 14, 2021 | 12:15 PM 6

CENTRAL COAST PHYSICIANS

Spring 2021

President’s Message: Here we are, over a year since the pandemic began. We have faced hurdles initially in providing a test, then a treatment, and now a vaccine. We have faced the anticipation of the severity with each wave, the pangs of the economic consequences, and political division. Scientific innovation and collaboration has achieved so much to help society move forward.

Here’s to nineteen things learned during the COVID-19 pandemic: 1. The importance of leadership and clear public health guidance 2. The persistence of inequities and systemic injustice in the health system 3. The beauty of a pause - we have simplified some aspects of life 4. The capability of a virus and the capability of hyper-accelerated life-science research

PRITI GAGNEJA, MD, PRESIDENT

5. Science’s limitless potential

Spring 2021

CENTRAL COAST PHYSICIANS

ADVOCATING FOR IMPROVED

MENTAL HEALTH CARE A COMMITMENT TO MENTAL HEALTH: For decades, CMA policy has strongly supported adequate funding and provisions for high-quality mental health care. Despite increased awareness, mental illness continues to go unrecognized and underfunded in California—and many people with mental illnesses do not receive the help they need. CMA strongly supports policies to improve the mental health system. CMA also supports increased funding for mental health services across all settings. MENTAL HEALTH ADVOCACY: Since 2009, CMA has taken positions on more than 50 bills on mental health issues such as psychotropic medications, outpatient treatment, mental health coverage and reimbursement, early intervention and prevention, involuntary commitment and emergency care, as well as the intersection between the justice system and mental health care. CMA also regularly works with stakeholders focused on mental health system reform to develop shared goals, and jointly craft and advocate for actionable solutions. COORDINATED MENTAL HEALTH CARE: CMA “CMA gives me a sense that I am not alone in the fight to protect my patients and ensure that they get the best and highest quality of care. It gives me an opportunity to stand with others.” C. Freeman, M.D. Psychiatrist Member since 2006

supports a multi-disciplinary model of integrated care for mental health patients, including increased collaboration with primary care physician providers to better coordinate health care delivery.

MENTAL HEALTH CARE IN UNDERREPRESENTED POPULATIONS: CMA has strong policy in support of public health campaigns and partnerships that support the unique needs of underserved populations, promoting culturally and linguistically competent mental health services for diverse and multi-ethnic communities.

QUESTIONS? CMA’s live-person call center is available Monday through Friday during business hours at (800) 786-4262 or via live chat at cmadocs.org. 8

CENTRAL COAST PHYSICIANS

Spring 2021

6. Coping skills – learning to cope with uncertainty, embrace changing environments and becoming adaptable

14. The value of relationships that exist, especially during a lockdown in pandemic

7. The importance of mental health

15. The negative impact of isolation which can lead to accelerated decline and depression

8. The miracle of the internet allowing 2-D engagement Zooming and electronic communication skills enhanced 9. The power of nutrition and lifestyle and the influence of risk factors in infectious disease 10. The value of nature, parks and beaches, and the importance of preserving these beauties 11. The concept of a front-line worker and respect, love, and gratitude for all kinds of front line workers

16. The power of the immune response to a contagion 17. The functionality of emergency use authorizations 18. How pausing impacted the environment- improved air quality and reduced water pollution 19. How to come together in unimaginable and innovative ways to help each other

12. The deeper understanding of the transmission of infectious disease by aerosols

With 56 million vaccinated in the US so far and all the knowledge gained in the year, we are approaching a place of hope.

13. The importance of avoiding panic and pessimism - buy and hold your stocks!

Stay positive and stay safe, Priti Gagneja, MD, President

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Spring 2021

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CENTRAL COAST PHYSICIANS

TENET HEALTH CENTRAL COAST’S NEW AFFILIATION WITH UC SAN FRANCISCO

NATIONAL EXCELLENCE AT A

COMMUNITY LEVEL Tenet Health Central Coast is proud to announce a unique, new affiliation with the University of California, San Francisco and UCSF Health to provide an even stronger network of neurological and spine care services on the Central Coast. Combining UCSF’s nationally-recognized expertise with advanced technology – that includes real-time consultations from neurosurgeons and experts during surgery – has created a new level of care for our community. The neurosurgical affiliation with UCSF Health further elevates Tenet Health Central Coast’s ability to provide state-of-the-art triage and care to any patient in San Luis Obispo County with acute or non-emergent neurological disorders involving the brain, spine or peripheral nerves in a seamlessly integrated fashion, any time of day. Neurosurgeons at Sierra Vista Regional Medical Center have around-the-clock access with UCSF Health neurosurgical providers to discuss any neurosurgical patient at Sierra Vista who could benefit from more complex care at UCSF. A continuum of care between the two organizations ensures that patients remain connected to their surgeons and specialists regardless of which facility they require. “We want to make sure our communities know we have a robust, high-quality neuro program right here in their backyard through our affiliation with UCSF Health. If patients can avoid transfers or traveling for surgery, we believe the chances are better for their recovery,” said Mark Lisa, CEO of Tenet Health Central Coast. “This is an excellent fit, and we are thrilled to collaborate with UCSF Health for national excellence at a community level.” The goal of this collaboration is to continue providing a high level of neurosurgical and spine care locally, while also providing direct access to UCSF Health specialists. Sierra Vista and UCSF Health physicians will work hand-in-hand to enhance the patient experience via immediate expertise for emergent, urgent, semielective neurosurgery consultations and transfers. One of the key aspects that makes this relationship unique to the region is the aforementioned continuum of care between the two organizations that ensures a patient’s clinical pathway will keep them connected to their surgeons and specialists regardless of which facility they may require. This relationship will allow physicians to

CENTRAL COAST PHYSICIANS

work firsthand with their counterparts at UCSF Health to utilize their expertise during crucial situations. As an Advanced Thrombectomy Capable Stroke Center, a Blue Distinction Center+ for Spine Surgery and the only designated trauma center in San Luis Obispo County, Sierra Vista is an ideal partner for UCSF on the Central Coast. Moreover, Sierra Vista has state of the art technology, such as advanced surgical microscopes with technology that allows Sierra Vista Neurosurgeons to fluoresce tumors and vascular blood flow in real time, which allows the surgeon to resect a greater portion of brain tumor cells and perform other advanced neurosurgical procedures. This technology is the first in San Luis Obispo County. “Our neuro services at Sierra Vista also include our advanced stroke care program with our local interventional neurology team that responds to emergencies 24/7/365. By adding direct access to UCSF physicians in their Department of Neurological Surgery, known as one of the best in the country, we are bringing top notch care and expertise to our community,” said Phillip Kissel, M.D., Director of Neurosciences at Sierra Vista and Clinical Professor for the UCSF Department of Neurosurgery. “This relationship is more than expanding access to expertise at UCSF; we are looking to introduce new programs and services locally in direct support of our community and its needs. I believe this affiliation will have a tremendous, positive impact on our Central Coast community.” Indeed, UCSF Medical Center is recognized by U.S. News & World Report to be among the top two adult neurology and neurosurgery hospitals in the country – and best on the West Coast, providing a full range of exceptional neurosurgical subspecialty care. “The UCSF Department of Neurological Surgery is proud to work with Sierra Vista Regional Medical Center to provide comprehensive, leading-edge treatment for complex neurosurgical cases, including pediatrics, in the central California community,” said Mitchel Berger, MD, Professor, UCSF Department of Neurological Surgery and Director, Brain Tumor Center.

Spring 2021

CENTRAL COAST PHYSICIANS

Stronger Together

Your Partners in Neurosurgical Care Together, with the University of California, San Francisco (UCSF), Sierra Vista Regional Medical Center is providing a stronger network of neurosurgical services on the Central Coast. Combining nationally recognized expertise and advanced technology, we can help keep you close to home for specialized neurosurgical care. Why Choose Sierra Vista Regional Medical Center? • Integrated care with UCSF Medical Center, which ranks number two in the nation and best in California in neurology and neurosurgery by U.S. News & World Report • Advanced technology for enhanced precision of brain and spine procedures • Advanced Thrombectomy Capable Stroke Center Certification • Blue Distinction Center+ for Spine Surgery • The only designated trauma center in San Luis Obispo County

To meet our specialists, visit TenetHealthCentralCoast.com/UCSF

CENTRAL COAST PHYSICIANS

Spring 2021

New UC Santa Barbara Student Health Executive Director BY ANDREA ESTRADA

UCSB Student Health welcomed a new executive director, Dr. Vejas Skripkus. Skripkus comes to UC Santa Barbara from the University of Southern California, where he served as a clinical assistant professor for family medicine at USC Student Health. Prior to that, from 2008 to 2017, he directed the campus’s Eric Cohen Student Health Center, which, under his leadership, attained its first accreditation from the Accreditation Association for Ambulatory Health Care. In announcing Skripkus’s appointment, Vice Chancellor for Student Affairs Margaret Klawunn cited his dedication to student health management and to providing the best healthcare possible to undergraduate and graduate students. She also recognized Dr. Ali Javanbakht for his committed leadership as Student Health’s medical director and interim executive director. In addition to holding a Master of Health Administration, Skripkus is a certified infection control specialist and has a

Spring 2021

Certificate in Healthcare Leadership. “I am humbled by the opportunity to lead the excellent department of student health at UC Santa Barbara,” said Skripkus. “And I am grateful for the leadership and warm welcome of the interim executive director, Dr. Ali Javanbakht, and the entire student health management team.” The university’s reputation as an academic leader with a diverse community and a collaborative environment drew Skripkus to the seaside campus, he said, adding that he looks forward to getting to know and understand the needs of the students here and continuing to implement best practices in quality, patient care, clinical guidelines, and care design. “I have spent my entire professional career working in university health care settings,” he noted. “I am very much drawn to the excitement and enthusiasm of undergraduate and graduate learners,” he said. Original published in The Current, UC Santa Barbara

CENTRAL COAST PHYSICIANS

RISK TIP

MALPRACTICE CLAIMS FROM THE COVID-19 PANDEMIC MORE QUESTIONS THAN ANSWERS BY ROBERT E. WHITE JR., CHIEF OPERATING OFFICER, THE DOCTORS COMPANY

The pandemic has raised pressing questions around preventive measures, vaccines, and safe treatment, but it has also obscured one key lingering uncertainty for medical professionals: Where are all the medical malpractice claims? A variety of factors create a cloud of uncertainty around when, if ever, we will see the claims we expected from care provided just before the pandemic, much less claims deriving from care during the pandemic of both COVID-19 patients and non–COVID-19 patients.

MALPRACTICE CLAIMS TAKE TIME TO SURFACE We won’t know until 2022 or later whether there will be an increase in claims related to the pandemic. When a medical error occurs, it’s not like an automobile accident. Everybody nearby knows when there’s been an automobile accident because they hear screeching tires, a loud crash, and then sirens. But when a medical error occurs, generally speaking, neither the doctor nor the patient immediately knows that something is amiss. It can take months or years for people to realize that something untoward has occurred. Claims from medical errors that occurred before the pandemic bring additional uncertainties. In 2020, we saw fewer than expected

CENTRAL COAST PHYSICIANS

Spring 2021

overall claims filed from events occurring 18 to 24 months before the pandemic. In total, 20 percent fewer claims were filed than in 2019. This may have had to do with courts shutting down, people being reluctant to meet with attorneys to discuss a claim, and/or lawyers working from home. We may see these claims filed later than expected, or maybe we won’t see them at all. But without a doubt, pandemic-related claims will be filed. The pandemic’s impact on physicians increases the risk of claims. Burnout is a major cause of medical errors, and a recent study found that out of 60 countries, U.S. healthcare providers showed the highest rates of burnout. We’re concerned about the stress affecting physicians’ performance—not just the physical stress of the demands put on them while treating COVID-19 patients, but all of the worry. For instance, a lot of doctors at the start of this pandemic stayed at hotels because they didn’t want to bring the virus home to their families—if they got exposed. Those sorts of stressors from life disruptions, on top of the stress of treating COVID-19 patients and the stress of treating non–COVID-19 patients within overtaxed healthcare systems, contribute to the possibilities for error.

IMMUNITY PROTECTIONS ARE NOT FAIL-SAFE And while healthcare providers have medical liability protections during the pandemic, these protections may not prevent claims. Healthcare provider pandemic-related liability laws vary from state to state, and they will be tested in the courts as to whether they’re constitutional. For example, there is pending legislation in New York State that would repeal the provider protections created there at the start of the pandemic. Further, some expert witnesses will couch their statements in terms of what it takes to get around one of these statutes. Therefore, physicians do have reason for concern, even in states with strong liability protections. The following case example, which is one of about 40 COVID-19–related claims made against our members so far, is a poster child for why these protections are necessary: A quadriplegic patient with COVID-19 had reached the point of organ failure before he reached the emergency room. There was really nothing medical science could do for him at that point, in terms of a chance at recovery. Therefore, the patient’s physician and conservator placed him in assisted living for palliative care. This was a sad but reasonable decision during a pandemic, with hospital beds needed for patients with a shot at surviving. Following that patient’s death, the physician is being sued.

DEFENDING CLAIMS REGARDING TREATMENT VS. REGARDING INFECTION CONTROL

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

We are very confident in our ability to protect our members against claims where they are being sued over the treatment of the disease. Claims arising out of treatment are not concerning to us because there is no cure for COVID-19—one can only treat the symptoms as the virus runs its course. On the other hand, suits harder to defend would be those that revolve around transmitting the disease because providers didn’t follow guidelines from the Centers for Disease Control and Prevention (CDC) or there wasn’t enough personal protective equipment (PPE). That’s why we stress the importance of following CDC guidelines, and why we’ve taken proactive steps to communicate with the entire medical community throughout the pandemic as part of our commitment to serve those who provide care. 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.

savings!

Spring 2021

CENTRAL COAST PHYSICIANS

Spring 2021

PHYSICIAN HEALTH & WELLNESS IN THE ERA OF THE COVID-19 WORLD BY DOUGLAS P. MURPHY, MD

PANDEMIC – PART I It’s been a year. A whole year. On March 11, 2020, the World Health Organization formally declared COVID-19 a world pandemic. Now, more than a year later, we are still in the midst of the COVID-19 world pandemic with hope for an end in sight but also with great uncertainty ahead. Not since the 1918 Influenza Pandemic, the so-called “Spanish Flu,” has a natural disaster had such profound and global effect. The year 2020 has been the deadliest in in regard to a natural disaster in US history. The impact the pandemic has had on doctors cannot be overstated. Presently, the greatest threat to physician health & wellness is the current COVID-19 pandemic. If not now, when? It’s time to get serious about Physician Health & Wellness. “I’ve seen so much suffering, lost patients to COVID, have seen tears & fears from patients, have other patients who feel the brunt of the economic and emotional breakdown lockdown has caused, other with non-COVID problems who have to cope differently and often less effectively with their own serious medical problems due to the new world that’s become because of COVID. Despite all this pandemonium and scrambling I am proud that we have found ways to adapt, found tests and treatments, and even a vaccine in record time. I feel a great joy and faith in science and that is rewarding.” – A RESILIENT INTERNIST, SANTA BARBARA, CA

In this installment in our series of Physician Health & Wellness, it seemed ingenuine not to address the issue in the context of the COVID-19 world pandemic. It’s a large, timely and very important topic. Hence, this is the first in a 2-part series. In the first part I will begin with a brief history of the pandemic and the current state of COVID-19 in the world. I will delve into the effects of the pandemic on physicians both professionally and personally due to the generous comments by colleagues of their own personal experience.

In the next article, the second in the series on Physician Health & Wellness in the Era of COVID-19, I will look at how physician’s experience with COVID-19 effects mental health issues, provide some resilience enhancing strategies for coping with these. Finally, I will update where we are in regard to the hope of new COVID-19 vaccines, the quest for herd immunity and the threat of novel COVID-19 variants. These variants represent a very credible threat to ending the pandemic.

WHERE TO FIND HELP California Medical Association (CMA) www.cmadocs.org/wellness Meeting the need of physicians’ challenges at the organizational and systemic level while providing innovative resources to help physicians prevent or address burnout. American Medical Association (AMA) www.ama-assn.org/amaone/ equipping-physicians-manageburnout Free, easy-to-use online resources, quick tips on implementing practice

“It’s been a year of doctors courageously stepping up and caring for patients often at great risk to themselves and their families. It’s been a year when the character of the house of medicine has shone as it ever has at other times of great need.” – PSYCHIATRIST, SAN LUIS OBISPO, CA.

Spring 2021

improvement strategies and exclusive insights into how other physicians manage burnout.

CENTRAL COAST PHYSICIANS

‘Closedʼ and ‘openʼ conformations of the spike protein on SARS-CoV-2, which binds to receptors on human cells. A common mutation (circled) seems to make the protein favour open conformations, which might mean the virus can enter cells more easily. Source: Structural data from K. Shen & J. Luban

respiratory distress and other complications. The virus was identified in January 2020 as a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for the coronavirus disease of 2019 (COVID-19). Travel-associated cases of COVID-19 were reported outside of China as early as January 13, 2020, and the virus is thought to have spread to all nations. Italy suspended flights to China and declared a national emergency after two cases were confirmed in Rome. As the virus spread case numbers began to increase rapidly. In February, municipalities in northern Italy were placed under quarantine. ICU cases started to appear in the hospitals that were ill prepared for the surge of COVID-19 cases. The world watched in awe as the Italian health system was overwhelmed by unprecedented levels of severe

CASES INCREASED FROM 150 ON FEBRUARY 23 TO 59,138 ON MARCH 22, NEARLY A 400-FOLD INCREASE IN A SINGLE MONTH. THE BEGINNING – THE FIRST WAVE OF COVID-19 In December 2019, Wuhan, China, became the center of an outbreak of viral pneumonia thought to have started from a zoonotic transmission event associated with a large seafood market. Many patients became hospitalized in Wuhan with viral pneumonia that had significant capacity to cause severe illness and death by acute

CENTRAL COAST PHYSICIANS

Spring 2021

illness and death. By March 9, a nationwide lockdown was instituted. Cases increased from 150 on February 23 to 59,138 on March 22, nearly a 400-fold increase in a single month. According to Sandra Zampa, undersecretary of Italy’s Health Ministry, "Italy looked at the example of China ... not as a practical warning, but as a 'science fiction movie that had nothing to do with us.' And when the virus exploded, Europe ... 'looked at us the same way we looked at China.'” In the United States, the first detection of SARS-CoV-2 was identified in Washington state on January 19, 2020, travel related. On January 20, the CDC began screening for COVID-19 at JFK, San Francisco and LAX. Community transmission of SARS-CoV-2 was confirmed in late February, when a California resident contracted the virus despite not meeting any of the travel exposure criterium. While Seattle was noted to be the first observed transmission of SARS-CoV-2 from China, the largest SARS-CoV-2 outbreak in the US was in New York City whose isolates were seeded on multiple introductions from Europe. From March 1–19, 2020, the number of reported COVID-19 cases in the United States rapidly increased from 74 to 13,677, and the virus was detected in all 50 states. By spring, New York City had become the epicenter of COVID-19 in the US with approximately 203,000 cased identified between March and May 2020. The rapid rise in cases quickly made contact tracing, unsustainable. Concerned communication from Gov. Andrew Cuomo was grim. “We have 35,000 hospital beds available,” Cuomo reported at a briefing on March 22. “Right now, the curve suggests we could need 110,000 hospital beds.” Cuomo required hospitals to increase capacity by at least 50%, with a goal of doubling their bed count. New York hit its peak of the “first wave” in early April. By June 2020 New York state suffered more than 30,000 deaths by COVID-19. It’s a toll worse than any scourge in recent memory, but, overall, the health care system didn’t run out of beds. Again, the nation watched in awe. The first case in California was an Orange County man who tested positive for COVID-19 on January 25, 2020, the first confirmed case in the state. He had recently traveled to Wuhan. This was the third confirmed US case. On January 29, around 200 Americans, including U.S. diplomats and their families, escaping the coronavirus outbreak in Wuhan, landed at the March Air Reserve Base in Riverside County. More cases are identified including the first person-to-person transmission in the state: A San Benito County man who had recently travelled to Wuhan, passed the virus to his wife. Santa Clara County was the first county to declare a local health emergency on February 3 due to coronavirus. The first COVID-19-related death occurred on February 6 in Santa Clara county, the first in the US. On February 16, passengers and crew members from the Diamond Princess, a cruise ship quarantined in Japan, are flown to Travis Air Force Base in Fairfield, California, and quarantined for 14 days; over 700 passengers eventually test positive. The first community transmission case in the US was a Solano County woman who tested positive on February 26. She had no known exposure to the virus through travel or close contact with someone known to be infected. By late February, California case

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PHYSICIAN SUPPORT LINE 1.888.409.0142 Volunteer psychiatrists offering free and confidential counseling to physicians and medical students.

NATIONAL SUICIDE PREVENTION LIFELINE 1.800.273.TALK Free, confidential support on a 24/7/365 basis to anyone of any age.

LOCAL RESOURCES Cottage Health www.cottagehealth.org/ coronavirus-covid-19/wellness/ Dignity Health www.dignityhealth.org/centralcalifornia/classes-and-events/ community-wellness-program Sansum Clinic www.sansumclinic.org/medicalservices/medical-service/details/ health-education-classes-events

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counts begin to rise dramatically. On March 4, Gov. Newsom declares a state of emergency and mandates out-of-state health care workers may assist in California hospitals. On March 6, Stanford University moves online and cancels large events after a faculty member tests positive. March 12 sees sporting events cancelled and Disney Parks closed. On March 13, President Trump declares COVID-19 a national emergency. On March 19, Gov. Newsome authorizes a statewide shelter-in-place order. This exponential surge of cases and unprecedented onset of severe illness and death worldwide was the beginning of the first wave.

THE CURRENT STATE OF COVID-19

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CENTRAL COAST PHYSICIANS

The first wave lasted from approximately March 15 and June 30. In the US, New York City was the hardest hit likely because of the high population density and little time to prepare. Hospital systems were completely overrun with shortages of just about everything but beds. News reports resembled “healthcare horror” more than any type of medical reporting the nation had actually experienced. Front line health care workers were confronted with levels of severe illness and death from COVID-19 on a scale almost impossible to imagine. Psychic numbing, a lack of feeling associated with information, because the feelings elicited by information that got worse each day and didn’t seem real. Like the collapsing of the Twin Towers on September 11, 2001, we had no frame of reference for this type of event. While health systems across the nation prepared for as best as they could, cases and deaths quickly spread to other parts of the country. Public health measures, chiefly social distancing, the wearing of masks, and of course, hand sanitation were instituted to “flatten the curve.” Ultimately, sheltering-in-place orders were instituted hoping to avoid the experience of New York City. In general, this was avoided though death rates in most metropolitan areas hit levels not seen by a natural catastrophe by anybody living today. Medical efforts focused on acute treatments, which were initially not significantly effective, and the race to develop a vaccine. As fall settled in, a number of factors led to an even larger surge in cases in the US resulting in the second wave. Case rates and deaths in the US began to rise in late October began to spread across the nation. On September 11, 2001, 2,977 people tragically lost their lives in the attack on the Twin Towers. During the peak of the second wave of the pandemic from December 2020 to January 2021, daily deaths in the US approached and for a time surpassed this number. On January 12th, the US recorded 4,459 deaths – the most in a single day. Of great significance is the approval of vaccines developed

Spring 2021

by Pfizer/Biontech and Moderna a week apart in December, with Johnson & Johnson’s vaccine receiving approval in late February. A monumental technological achievement that should not be overlooked. Arms were “jabbed” with vaccinations initially with front line health workers and nursing home residents and staff. New cases and deaths remained high through February when the first hopeful news came with falling case rates and deaths and the hope

self-interest. However, though medical training is highly rigorous and most doctors are exposed to the inevitability of patient death in medical school, the unprecedented scale of severe infection and death associated with COVID-19 has taken a toll on doctors providing direct patient care. In cities across the US and around the world, frontline health care workers (FHCWs) have been exposed to an extreme and sudden rise in daily workrelated stressors witnessing severe illness and death at unprecedented rates, while experiencing threats to their own safety, leading to significant concern for the psychological impact of this crisis within this population. The overwhelming stress on doctors driven by a combination of witnessing and empathizing with the fear and suffering of very sick patients, many of whom were going to die, associated with profound helplessness to alleviate the suffering may be scarring to many doctors who are trained to be of help and be in control of situations. The stories in ER’s and intensive care settings of patient’s saying goodbye to loved one’s while being intubated, not knowing if they would live through the experience and see them again is just one touching example of this helplessness doctors experienced.

A NEW SURGE OF COVID-19 CASES IS PRESENTLY MOVING SWIFTLY ACROSS EUROPE REPRESENTING A THIRD WAVE OF THE PANDEMIC. of truly effective vaccines going out. At that time, it seemed that the worst was over and the steady rollout of vaccines would lead us steadily out of the pandemic. Present numbers for COVID-19 pandemic from Johns Hopkins as of March 27, 2021 were, worldwide 125,727,107 COVID-19 cases and 2,777,541 deaths (2.2%). In the United States there were 30,218,682 cases and 548,828 deaths (1.8%). By comparison, World War II was associated with 419,400 American deaths, World War I 117,466 American deaths. The year 2020 has been the deadliest in US history due to a natural catastrophe. In California, there were 3,635,640 cases, 58,346 deaths (1.6%), 16,775,843 vaccines administered with 28% of the population has received a first dose of vaccine. In Santa Barbara, there were 33,945 cases, 435 deaths (1.3%) and157,562 vaccines administered. In San Luis Obispo, there were 20,402 cases, 255 deaths (1.2%) and 14,520,575 vaccines administered. A new surge of COVID-19 cases is presently moving swiftly across Europe representing a third wave of the pandemic. This is thought to be attributable to slow vaccination campaigns and the emergences of 3 new variants of COVID-19 which are more infectious. Case rates are rising in the US as well. According to Johns Hopkins Weekly COVID-19 Update dated March 26, there were 31 states with rising cases for 1 week, and 17 states with rising cases for 2 weeks and increase over 25 states and 8 states the week prior, respectively.

COVID-19 EFFECTS ON PHYSICIANS For most physician, the practice of medicine is as much a calling as it is a profession. The calling of this practice is rooted in the character of the physician whose daily decisions and patient interactions are the outcomes of a commitment to values that supersede one’s own

Spring 2021

“Dealing with the tragedy and allowing the appropriate visitors for folks who we think will die soon is a real challenge. No one should die alone, without access to their loved ones, if it can be avoided.” - EMERGENCY PHYSICIAN, SAN LUIS OBISPO, CA “I had a very sick but not sick-enough-for-hospitalizationpatient with COVID pneumonia who asked me the other day, ‘Doctor, am I going to die?’ She is higher risk. I know that and have to explain that and also offer hope about she can do right now. My heart breaks but I have to stay strong to provide support for these patients.” – INTERNIST, SANTA BARBARA, CA

According to Medscape’s US & Int’l Physician’s COVID-19 Experience Report published September 11, 2020, Emergency medicine physicians are most likely to treat patients with COVID-19 in person. Due to COVID-19’s pulmonary effects, pulmonologists are also heavily involved. These doctors and their staffs likely put themselves at the greatest risk. “I have personally felt significant fear of personal risk

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and vulnerability during the COVID-19 pandemic. Having attended patients younger than myself with no comorbidities, come into the ED with serious COVID illness and later learning that several of them went on to die makes one very aware of how real the risks can be. The fact that I could unknowingly bring COVID home to my family is constantly in the back of my mind.” - EMERGENCY PHYSICIAN, NASHVILLE, TN

Physicians have consistently put themselves at risk despite risks to their personal and family health, their income, and emotional health have been sorely affected by the pandemic. According to Medscape, as of March 11, 2021, the anniversary of the day the WHO declared COVID-19 a “pandemic,” there have been more than 3030 deaths of healthcare workers from 90 different countries worldwide due to COVID-19. The overwhelming majority of these are the result of exposure to the virus in the performance of their duty, caring for patients. “It is challenging that in the tight working environment of the ER with other staff working 3 feet from you, without a mask and talking, for a prolonged period of time. I have experienced several times when a colleague come down with COVID right after I spent 10 hours working next to him or her, often with removal of mask. That’s when the fear kicks in and you begin counting down COVID’s incubation period until you know you are safe.” - EMERGENCY PHYSICIAN, NASHVILLE, TN

Significant challenges exist for physicians in keeping up with and dealing with confusion around the myriad of changes regarding COVID-19. Changing protocols for treatment, changing schedules for vaccinations, “anticovids” and “antivaxers”, and any other type of change related to the care of patients who may or may not have COVID-19. “Challenges being faced in the administration of care - from an internal medicine standpoint in primarily outpatient care, challenges include dynamically changing information, changing with testing criteria, testing options, testing availability, testing turnaround times, questions from the public about these things, about possible false results, questions and variations on quarantine times. changing to telemedicine overnight, inching back around to in office visits and migrating back to telemedicine...“ – INTERNIST, SANTA BARBARA, CA

Though initial stresses arose with doctors treating COVID-19 patients without the provision of proper personal protective equipment (PPE), a year of working in and out of PPE brought significant stresses of its own.

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“It is a challenge to always be protected with appropriate PPE in every situation. The need for PPE slows everything down and is physically challenging as well. We are now boarding patients longer in the ED who we know have to be admitted because of lack of staffing issues on the floors and in ICU. We are back to some of the problems we have had years ago with throughput, but Covid is the cause now.” - EMERGENCY PHYSICIAN, SAN LUIS OBISPO, CA “I'm on for the next 4 days in the ER. I wear a paper gown for all likely cases, and an N95 and face shield for all patients. My ears are about to fall off and I'm so burned out from of wearing all this PPE - constantly in and out of it – I must have filled an entire landfill with the amount of garbage I've created.” - EMERGENCY PHYSICIAN, SAN DIEGO, CA

Adding to the stress, a majority of physicians saw some decline in demand for their services and earnings. “Most often, US physicians saw a decrease in income of 11%-50%. The US specialists whose incomes decline by 51% or more were ophthalmologists, allergists, plastic surgeons and otolaryngologists.” In some cases, it was emergency medicine physicians who saw a decrease in volume of work but significant increase in the intensity of it. “It is ironic when the work on the front lines is riskier, and more physically and emotionally challenging than it has ever been, while facing a financial penalty at the same time. We are lucky that our local hospital systems, who are also taking a financial hit, have been able to provide us with the appropriate PPE, equipment, and meds that we need in this crisis.” - EMERGENCY PHYSICIAN, SAN LUIS OBISPO, CA

CONCLUSION The COVID-19 world pandemic is presently the greatest threat to physician health & wellness is the current COVID-19 pandemic. The first half of this article, detailing the origin and onset of the pandemic showed an overview of the profound and unprecedented stresses the pandemic has put on people, institutions, government, and in particular, the medical profession and its institutions. The second half delved more into specific issues and comments by practicing physicians who were generous enough to share their thoughts and challenges on specific challenges they face practicing medicine in the era of COVID-19. It is clear that overwhelming stress is at play in the routine practice of medicine and that this is going to have a profound effect on the health and wellness of physicians. It is predicted that this effect will outlast the COVID-19 pandemic significantly. If not now, when? It’s time to get serious about Physician Health & Wellness.

Spring 2021

Feel More Empowered in Just 30 Minutes Struggling to find balance in your work and personal life amid the pandemic? Frustrated, angry or anxious that public health guidelines are ignored while COVID-19 remains prevalent? Experiencing racial or social injustice? Worried about your financial stability? Feeling burned out, unable to sleep or wishing you could just talk to someone who understands? Did you have an emotional response as you read these questions? It’s okay. CMA Wellness understands.

The California Medical Association’s wellness initiative (CMA Wellness) supports the well-being of the state’s health care workers with free and confidential peer coaching. Through Care 4 Caregivers Now (C4CN), clinicians will: Partner with a trained peer coach for free and confidential virtual sessions (via Zoom) that are held weekly for 30 minutes (no mandated reporting requirement) Receive emotional support to feel calmer, more focused and in control Find clarity and peace to better plan for the future Our trained coaches are fellow clinicians who understand the rigors and emotional stresses of the profession and know the value of a safe, confidential and non-judgmental space. Coaching is available for physicians (M.D. and D.O.), physician assistants, nurse practitioners, registered nurses, certified respiratory therapists, registered respiratory therapists, residents/fellows, medical students, public health officers and medical reserve corps volunteers.

REQUEST FOR ANNUAL APPLICATIONS AND NOMINATIONS FOR

Standing Councils and Subcommittees The Board of Trustees, via its Committee on Nominations, is seeking recommendations for CMA member physicians who are interested in and willing to serve on its standing Councils and Subcommittees for 2021-2022. All current appointments expire at the conclusion of the CMA House of Delegates in October 2021. New appointments will begin their terms at that time, with the new terms expiring at the conclusion of the 2022 House of Delegates. Councils and committees meet as needed, with up to four (4) meetings per year via teleconference and potentially one (1) inperson meeting. In developing nominations, we urge special consideration for recruiting the talent and experience of your younger colleagues, as well as ethnic and women physicians, who will bring new perspectives to the Association’s policy-developing committees.

Councils and Subcommittees Council on Ethical, Legal and Judicial Affairs Subcommittee on Professional Liability Council on Health Professions and Quality of Care Subcommittee on Continuing Medical Education Subcommittee on Medical Board of California Subcommittee on Physician Wellness and Professional Satisfaction Council on Legislation Council on Medical Services Subcommittee on Health Information Technology Subcommittee on Medi-Cal Subcommittee on Medicare Subcommittee on Workers’ Compensation Council on Membership, Governance & Bylaws

Please submit applications through the form on the CMA website at www.cmadocs.org/nominations/submit. The deadline for submission is 11:59pm on Monday, June 7, 2021.

INSTRUCTIONS FOR NOMINATIONS/APPLICATIONS:

• Please verify the applicant’s willingness to serve, if selected, prior to submitting the application. • A ll endorsements, if secured, must be stated explicitly, either in the application form or via email to nominations@cmadocs.org. •A candidate may only apply for three (3) Councils and/or Subcommittees. (Note: You may see a warning on the website once you have selected all three, but you will still be able to continue with the submission.)

ALL NOMINATIONS MUST INCLUDE:

• Completed application form •C V (less than 5 pages) • Statement of Interest

FOR MORE INFORMATION, CONTACT: Jessica Arthur Governance Coordinator California Medical Association 916.551.2055 jarthur@cmadocs.org

Council on Science and Public Health

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Spring 2021

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Spring 2021

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CenCal Health NEWS HUB: Summer Camp for Children with Autism Pivots During Pandemic At the beginning of the COVID-19 pandemic, many Central Coast families abruptly found themselves in the stressful situation of having school-age children and working parents isolating at home – a total disruption of their normal routines, including education and employment. “Add a child diagnosed with autism to the mix, and the frustration is compounded for both the child and the family,” said Camp Mariposas Coordinator Kristen Landeros, M.A. Camp Mariposas is a summer day camp that provides speech and language with occupational therapies to children, primarily between the ages of 3 and 10 years, who have been diagnosed with Autism Spectrum Disorder or other conditions that would benefit from early and continuous intervention. A team of professional speech and language pathologists, movement and motor skill therapists, and behavioral specialists work closely with children to foster communication as well as physical and social development. In March of last year, camp staff quickly determined that they would need to pivot and “go virtual” with their Summer 2020 program. Fortunately, the organization had previous experience with providing online therapy to children who live in remote areas of the Central Coast, like Shandon and Creston. “We already knew that virtual therapy works. It had been validated,” said Silvia Wasjutin, founder of the Camp Mariposas program. “The first priority was to communicate with the parents,” explained Landeros. Camp staff needed to learn if the family had computer access and an

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internet connection. If the family’s only computer device was a mobile phone – usually in the possession of the working parent – then staff had to figure out when that phone would be available for the child. Scheduling and rescheduling campers’ telehealth sessions was an on-going challenge for Landeros and team. Another challenge was recreating the day camp experience, offering the familiarity and consistency that are so important to these children. Staff members put together age-appropriate “camp boxes” that were delivered to campers’ homes. The boxes included camp t-shirts – which campers and staff always wore when they were in-session – plus craft materials and therapy tools such as scissors, bubbles, balloons, and playdough. A welcome video was produced in English and Spanish that helped orient children and parents to

“ Without Change There Would be No Butterflies” the virtual camp. Families were asked to create a space at home, preferably a quiet corner, where the camper could participate online with their therapist. Parents received daily emails with links to additional education and therapy videos for their child and were required to attend weekly group training. Camp Mariposas also facilitated online parent support groups. “The coaching work that we did in 2020 with parents was some of the most rewarding of our achievements during the pandemic,” said Landeros. “Parents were able to talk to other parents about what they were going through, offering suggestions

Spring 2021

and encouragement. This kind of parental networking didn’t necessarily happen before the pandemic. It was definitely one of the positives to come out of 2020’s virtual camp.” Since 2017, Camp Mariposas has been solely funded by CenCal Health, the local Medi-Cal health plan in both Santa Barbara and San Luis Obispo counties. Mariposas Project, MP Health is a contracted provider of speech, occupational, and physical therapy services. These services are Medi-Cal covered benefits offered to children through the school system, Tri-Counties Regional Center (as authorized by California Children’s Services), or through CenCal Health’s medical benefit. “The prospect of a lapse in learning and treatment during the summer months for these children with occupational and speech therapy needs is alarming,” said CenCal Health CEO Bob Freeman. “For these children, who are our members, to overcome their conditions and thrive in the future is important to us. Providing funding for Camp Mariposa capsulizes the mission of CenCal Health.” Eligible children attend the summer program at no cost. In 2020, each camper received four hours of direct therapy per week for four weeks, plus daily activities that included one hour of speech and one hour of occupational therapy. Individualized “intensives” in speech and language pathology, physical therapy, behavioral support consultations, and parent training were also included in the camp sessions. For Summer 2021, Camp Mariposas is planning a hybrid program with both online and in-person sessions at the camp’s two locations in Santa Barbara and Atascadero. The enrollment is expected to double to 200 campers. “The word is out about the developmental therapies offered by our professional pediatric specialists,” said Wasjutin. “When public schools and services for special needs children were discontinued last year, Camp Mariposas was still there for our community.”

Spring 2021

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CMA Launches Free PPE Direct Shipment for California Physicians and Medical Groups The California Medical Association (CMA) is

county medical society or CMA’s online request

extending its distribution of free personal protective

portal.

equipment (PPE) with direct shipment of supplies to California physicians. The new online portal (www.cmadocs.org/ppe)

As of December 31, 2020, the effort had distributed a combination of 35 million masks, 35 million sets of gloves, 2.3 million isolation gowns,

offers California physicians the ability to register

2.5 million face shields, 400,000 hooded coveralls,

for specific types of PPE including coveralls, face

21 million N95 respirators, 3 million sanitizing wipes

shields, goggles, hand sanitizer, sanitizing wipes,

and 700,000 sanitizer bottles.

isolation gowns, N95 masks, surgical masks, and

“I’m really impressed with the distribution

vinyl gloves. The PPE is free, and the medical

operations to small- and medium-sized practices,”

practice pays a nominal cost for shipping and

said Richard Siedman, MD, Chief Medical Officer of

handling.

the LA Care Health Plan. “These medical practices

CMA distributed over 100 million pieces of PPE

are critical to the overall health care delivery system

to physicians and medical groups from August 1

in our state and enables physicians and their staff

to December 31, 2020. The donations supported

to more safely provide the care that their patients

approximately 100,000 California physicians and

need.”

their staff, which represented a total value of more than $200 million. “Lack of PPE throughout the COVID-19 pandemic

“These free PPE kits were a lifeline during a very challenging year,” said Elk Grove cardiologist Rajan Hundal, MD. “Without the donations, we

has compounded hardships for medical practices

would have had to limit hours or close our practice

and hindered physicians’ ability to serve patients,”

completely. The PPE helped our patient care team

said CMA President Peter N. Bretan, Jr, MD. “We

stay healthy and enabled us to continue serving our

knew we had to act – and fast – to help physicians

patients – our community is healthier because of

keep their practices open. What resulted was

this program.”

an unprecedented effort in the organization’s

The lessons learned during the PPE distribution

165-year history. CMA is grateful to our partners

effort will be applied to helping the state build its

for their collaboration and support, which

vaccination network.

ultimately helped so many Californians continue to receive health care.” Last summer, CMA partnered with local county

“The administration of COVID-19 vaccines brings hope into focus, but the global pandemic remains challenging,” said Dr. Bretan. “Equity and

medical societies to develop an entirely new

speed remain vital components of any successful

statewide distribution system for essential medical

vaccination strategy, and we cannot compromise

equipment, which included PPE donations from the

one for the other. The lessons learned distributing

Office of Emergency Services (OES).

PPE will guide CMA as we help the state build out

Within weeks, PPE was being moved from state

their robust vaccination network connected

warehouses, repackaged into individual kits, and

to community physicians that millions of

loaded on trucks to be handed out at drive-through

Californians already rely on for flu shots and routine

events across the state. Physicians and medical

vaccinations.”

practices also accessed PPE through their local

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Spring 2021

PPE Relief The California Medical Association partnered with local county medical societies and the Office of Emergency Services to deliver over 100 million pieces of personal protective equipment (PPE) to California physicians from August through December 2020.

PPE Distributed to Date: 100+ Million Pieces

21 Million

2.5 Million

400,000

35 Million

N95 Respirators

Face Shields

Hooded Coveralls

Examination Gloves

2.3 Million

35 Million

3 Million

700,000

Isolation Gowns

Surgical Masks

Sanitizing Wipes

Sanitizer Bottles

Total Value to Practices: $200+ Million To learn more about CMA’s PPE Relief efforts, visit cmadocs.org. Distribution is ongoing and these numbers are accurate as of January 1, 2021. Spring 2021

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Federal Information Blocking Rule Frequently Asked Questions

In May 2020, the federal Office of the National Coordinator for Health IT (ONC) published the 21 st Century Cures Act Final Rule, usually referred to as the “Information Blocking Rule.” After a delay related to the COVID-19 pandemic, the rule is now set to take effect on April 5, 2021. The Information Blocking Rule provides definitions and clarifications on Section 4004 of the 21st Century Cures Act, which was passed in December 2016 and signed by then-President Obama. That section of the act defined information blocking in law and required the U.S. Health and Human Services Agency (HHS) to issue regulations providing for more clarity.

What is “information blocking”? As defined in the 21st Century Cures Act, information blocking is a practice that is likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information. Put another way, information blocking is any act (or failure to act) that artificially restricts the free flow of patient health information.

What are physicians required to do under the rule? In short, starting on April 5, 2021, physicians are required to respond to any legitimate request to exchange or provide access to EHI stored in their EHR. Such a request could come from a patient, another provider, a health plan (seeking information for clinical purposes), or a public health agency. Initially, EHI is limited to a certain set of data (see below), but must be provided in the form requested.

What are some examples of information blocking? The 21st Century Cures Act offers some examples of actions that could be information blocking: +

Practices that restrict authorized access, exchange, or use under applicable state or federal law of such information for treatment and other permitted purposes under such applicable law, including transitions between certified health information technologies (health IT);

Implementing health IT in nonstandard ways that are likely to substantially increase the complexity or burden of accessing, exchanging, or using EHI;

Implementing health IT in ways that are likely to:

(Rev. 03/22/2021)

cmadocs.org 30

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CO NT ACT US (800) 786-4262 memberservice@cmadocs.org Spring 2021

INFORMATION BLOCKING RULE: FAQ

■

Restrict the access, exchange, or use of EHI with respect to exporting complete information sets or in transitioning between health IT systems; or

■

Lead to fraud, waste, or abuse, or impede innovations and advancements in health information access, exchange, and use, including care delivery enabled by health IT.

Does this rule just apply to physicians? No. This rule applies to all actors in the health care system – physicians and other health care providers, hospitals, health IT vendors, and health information exchanges. Health plans may be subject to the information blocking rule, depending on their business model. Plans are also subject to a separate rule released at the same time, the CMS Interoperability and Patient Access Rule.

Are physicians required to provide access to all data on the patient? Not yet. Until October 6, 2022, physicians are only required to exchange or provide access to data contained in the US Core Data for Interoperability version 1 (USCDI). Most of what is in the USCDI is data physicians are used to sharing with their patients and other providers – patient demographics, allergies, problem list, etc. The main change for physicians is that the USCDI includes both structured and unstructured clinical notes. Those notes will now be available to patients upon request.

Are there exceptions? Yes. The ONC has defined 8 exceptions that allow physicians to restrict access to patient information without it constituting information blocking: 1. Preventing harm exception – The physician believes that there is a risk the patient will come to physical harm if the data is released. 2. Privacy exception – Generally, this applies to situations where releasing information could result in violating HIPAA or state privacy laws (such as the Confidentiality of Medical Information Act in California). 3. Security exception – The Security exception applies when the practice believes that the release of the data would compromise the security thereof. 4. Infeasibility exception – This exception covers uncontrollable events (such as wildfires) as well as technical reasons (such as the inability of the EHR to separate data from data that cannot be released due to privacy laws).

(Rev. 03/22/2021)

cmadocs.org Spring 2021

CO NT ACT US (800) 786-4262 memberservice@cmadocs.org CENTRAL COAST PHYSICIANS

INFORMATION BLOCKING RULE: FAQ

5. Health IT performance exception - This exception covers cases where a health IT system is offline for scheduled or unscheduled reasons. 6. Content and manner exception – As noted above, until October 2022, physicians are only required to release data in the USCDI. This exception covers data requests outside of that set. Physicians should discuss this exception with their EHR vendor. 7. Fees exception – Practices are allowed to charge reasonable fees for providing data. This mostly applies to EHRs and HIEs. 8. Licensing exception – This exception also applies mostly to EHRs. It allows vendors to license technology without it constituting information blocking. Any use of these exceptions must be documented and is subject to a reasonableness standard. In addition, it must be applied in a non-discriminatory way.

What about data that is covered by federal (HIPAA) or state (CMIA) laws? As mentioned in exception #2 (Privacy Exception) listed above, physicians are not required to provide access to information that is protected under federal HIPAA rules or the state-level Confidentiality of Medical Information Act.

Are there penalties for physicians who engage in information blocking? Not yet, but there will be. The Information Blocking Rule implements civil monetary penalties for health IT developers (up to $1 million per instance), but not for physicians. The HHS Office of the Inspector General (OIG) is expected to issue a follow up rulemaking sometime in 2021 or 2022 laying out proposed penalties for physicians. CMA will make more information available about that rulemaking as it becomes available.

How will claims of information blocking be reported? Patients, physicians, and other actors will submit information blocking complaints directly to the ONC using their new information blocking portal. Complaints will be investigated by the HHS Office of the Inspector General (OIG).

Is there anything my EHR vendor has to do? Yes, there are three main requirements for EHR vendors. First, there are changes to the ONC certification rules that will guarantee that EHRs are able to exchange the data contained in the USCDI. (Rev. 03/22/2021)

cmadocs.org 32

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CO NT ACT US (800) 786-4262 memberservice@cmadocs.org Spring 2021

INFORMATION BLOCKING RULE: FAQ

In addition, EHRs will be required to provide a patient access API, where patients will be able to download their EHI into a smart phone application of their choice. Finally, any fees charged by an EHR vendor to a physician in order to exchange data must be reasonable, or they could constitute information blocking.

What are some first steps my practice can take right now? First, if your EHR vendor has not proactively informed you of their plans for coming into compliance with the Information Blocking Rule, you should contact them as soon as possible and ask for that information. It is very likely that your EHR system may need updates or add-ons, so you will want to get in the queue for those as soon as possible. Once you have done that, you will want to review your internal processes for responding to requests for patient information, both from patients and other providers. Any workflow process that you have that inhibits access to information should be reviewed very carefully. For example, if you routinely hold lab results for a set amount of time, that could be information blocking. Depending on your situation, you may wish to consult an attorney with expertise in privacy and security rules. The American Medical Association (AMA) has a compliance guide for physicians, available here: amaassn.org/system/files/2020-11/info-blocking-compliance.pdf

Where can I go for more information? The Office of the National Coordinator for Health IT has many resources on information blocking: healthit.gov/topic/information-blocking In addition, AMA has developed several guides for physicians on how to comply with the rule: amaassn.org/practice-management/digital/new-information-blocking-rules-what-doctors-should-know On February 18, 2021, the California Medical Association held a webinar in conjunction with the ONC for California physicians: cmadocs.org/store/info/PRODUCTCD/CMA21_0218_INFO

(Rev. 03/22/2021)

cmadocs.org Spring 2021

CO NT ACT US (800) 786-4262 memberservice@cmadocs.org CENTRAL COAST PHYSICIANS

F I S IE S A

POSITIONS AVAILABLE

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. Physician openings 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. Physician openings 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. Physician openings can be found at dignityphysiciancareers.org.

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. Physician openings can be found at www.sansumclinic.org/physician-provider-jobopportunities. 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. Physician openings 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. 34

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Spring 2021

Opportunity for Residents and Fellows to Shape Statewide Policy The Resident and Fellow Section (RFS) is currently seeking engaged and interested members to join their section and represent them at the 2021 House of Delegates (HOD). Resident and Fellow seats are one-year terms, during which the delegates and alternates will attend the House of Delegates, participate in the year-round resolution process, and engage with the Section on projects and policy discussions. TERM LENGTH/DURATION One (1) year: 7/1/2021 through 6/30/2022 TIME COMMITMENT Members are expected to attend the annual House of Delegates 2021 House of Delegates: October 23-34, Los Angeles [note: may be held virtually, TBD] Participate in and contribute to RFS meetings REQUIREMENTS Applicant/nominee must: • Be a Resident or Fellow member of the CMA in good standing • Agree to participate with a goal of developing the best policy for the Association

Spring 2021

INSTRUCTIONS Please submit nominations/applications to jarthur@cmadocs.org: • Completed Application Form (REQUIRED) • Brief CV (less than 5 pages) (REQUIRED) • Statement of Interest DEADLINE 11:59pm on Friday, May 28, 2021 For more information, contact: Jessica Arthur Governance Coordinator California Medical Association 916.551.2055 jarthur@cmadocs.org

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7 New & Rejoining The Central Coast Medical Association welcomes the following physicians as members

...and even more on the way. Richard Altesman, MD Psychiatry San Luis Obispo 805.541.6000

Sherif Michael, MD Gastroenterology Santa Barbara inSite Digestive Health Care 805.682.3585

Julian Davis, MD, MA Hematology Oncology Santa Barbara UCLA Health 805.563.0041

Karim Rasheed, MD, MSc Ophthalmology Templeton 805.434.2533

Garrett Foulke, MD Internal Medicine Arroyo Grande

RESIDENT Claudia Balderrama, MD General Surgery Santa Barbara Santa Barbara Cottage Hospital

Angela Hsu, MD Pediatric Critical Care Medicine Santa Barbara 805.682.7111

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Spring 2021

G N I S I T R A DV E

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In Memoriam

In Memoriam JOHN MICHAEL ACKERMAN, MD

1937-2020 John was born in 1937, the only child of Dr. Jack S. Ackerman, surgeon and obstetrician gynecologist, and Ilona (Ilus) Weiser, interior designer. His father’s cardiac health crisis at age 44, shaped John’s life, sparking his interest in the psychological impact of chronic illness on patients and their families. After graduating in psychology from the University of Michigan, John received his medical degree from the University of Wisconsin. While studying in Madison, he met his wife Ruth Watkins, and they married in 1963. He completed his straight medical internship at Mt. Sinai Hospital in Los Angeles, followed by his psychiatric residency in San Francisco at UCSF and Mt. Zion hospitals. From 1968-70 John served in the U.S. Public Health Service Division of Indian Health in Anchorage, Alaska, as director of psychiatric services for the indigenous people of the state. His pursuit of more training in community mental health brought him to Ventura County in 1970. He also began a part-time private practice in Santa Barbara. He was active in the Cottage Hospital Department of Psychiatry, Santa Barbara College of Oriental Medicine, the Family Therapy Institute, Medical

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Reserve Corps (adding acupuncture to their resources), Montecito Emergency Recovery and Action Group, League of Women Voters, and other nonprofits dedicated to improved health care delivery. After retirement, John was able to pursue his love of singing and his life-long dream of singing for live audiences. He loved spending time with his grandchildren, running on the beach with his kids and their golden retrievers, camping, skiing, hiking, bowling, and playing backgammon with his family. John is survived by his wife Ruth; son David; daughter Dara; daughter-in-law Gabrielle Perrin; grandchildren Amalia and Moses Ackerman; and his beloved extended family. Adapted from the Santa Barbara Noozhawk

THOMAS RICHARD ALLYN, MD

1946-2021 Tom was born in Springfield, IL on July 24, 1946 to Richard Allyn, MD and Ruth Allyn, RN. Tom completed his undergraduate studies at Northwestern University, and then taught school in inner city Chicago for two years before moving on to Columbia University College of Physicians and Surgeons. Upon graduating, Tom moved on to Massachusetts General Hospital where he completed his internship, residency, and

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In Memoriam

a fellowship in Nephrology. It was in his first days at MGH that he met his lifelong love, Denise. Tom and Denise married in 1975 and went on to have three wonderful children. In 1981, the young family moved across the country to Santa Barbara where Tom joined Michael B. Fisher, MD in his Nephrology practice. Soon after, Tom was named Chief of Nephrology at Santa Barbara Cottage Hospital and Co-Director of their Acute Dialysis program. He held these positions until 2016. In the 1980s, Drs. Allyn and Fisher established the Santa Barbara Artificial Kidney Center, the Lompoc Artificial Kidney Center, and the first successful multistation dialysis center in Leòn, Mexico. Through these endeavors he helped care for thousands of patients over many decades. He had such respect for his employees and a true love for his patients. Although medicine was Tom’s lifelong passion, he took even greater pride and joy watching his children grow and excel in their lives. In more recent years, Tom so enjoyed watching his grandchildren grow; each one bringing even more joy and love to his life. Tom is survived by his wife Denise; children Jenny (Dave), Kim (Chad), and Paul (Liz); grandchildren Summer, Christopher, Julia, William, and Taylor; as well as his siblings Barbara, Paul, and David. Adapted from the Santa Barbara Independent

ERNEST A. BLAKEY, MD

1922-2020 Dr. Ernest Blakey, a long-time Santa Barbara resident and former surgeon at Sansum Clinic, died at home. An AllAmerican basketball player at Brown University and a career medical officer in the Navy with service in WWII and the Korean War, he also, along with his late wife, Peggy, a former Navy nurse, did a wonderful job raising seven kids. A Red Sox fan of long standing, as well as being an exceptional cook, he was also an avid golfer, in his prime

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sporting a 3-handicap at Montecito Country Club, and from age 66 to 91 shooting his age or better every year. And, too, he made several trips to play historic courses in Scotland and Ireland, always enjoying fair weather, which he attributed to taking along his ‘lucky umbrella.’ He was known to all as an easygoing fellow with a lively wit, once describing one daughter’s initial efforts at making angel food cake as ‘being just thick enough to slip into the catcher’s mitt to take the sting out of the pitch.’ He is survived by his 7 children, 11 grandkids, and 14 great grandkids. Adapted from the Santa Barbara News Press

JOANNE SAVIO GAROFALO, MD

1934-2021 Born on July 20, 1934, in Chester, Pennsylvania, she was the third of four children to be born to Anthony and Mary Natale. Joanne’s father had been born in Italy, and her mother was the child of Italian immigrants. She often spoke of great traditions her parents taught her about life and her Italian heritage. From an early age, Joanne was a lover of science. She studied chemistry at Immaculata University in Pennsylvania and received her Medical Doctorate degree from the University of California, Irvine School of Medicine in 1960. From then on devoted her professional life to Family Medicine and helping others. In 1972, Joanne married Dr. Joseph Garofalo, a Santa Barbara podiatrist, and together they built a beautiful partnership for 49 years. She was extremely dedicated to serving her patients, as many had been in her care for 40+ years. Joanne was an accomplished physician but considered

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In Memoriam

In Memoriam her greatest joy to be a mother to her eight children. Throughout the years, she instilled her values in them: faith, family, and humility. Sunday dinners were a “must” in the Garofalo house, as Joanne enticed the whole family with her world-class cooking, especially pasta marinara, eggplant parmigiana, and homemade lasagna. Joanne enjoyed traveling to many destinations around the world. She particularly enjoyed family trips to Italy, time spent at a family home in Lake Tahoe, and frequently cruising different European ports of call. Her favorite was to cruise the Mediterranean and Caribbean. She is preceded in death by her parents and siblings. She is survived by her husband, Joseph Garofalo; her children Michael Bucci (Dana), Monica Casas (Tom), Maria McGuire (Tom), Anita Kuskey (Eric), Vincent Bucci (Sasi), Alicia Garofalo Foschi (Ubaldo), Joseph Garofalo (Alexis), Salvatore Garofalo (Amy); 25 grandchildren, and 4 greatgrandchildren. Adapted from the Santa Barbara News Press

THOMAS WILLIAM HAMILTON, JR, MD

1938 - 2020 Tom was born in 1938 and raised in Evansville, Indiana along with his three brothers and three sisters. Tom earned his Medical Degree from Indiana University

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School of Medicine and became a Family Physician in 1970. That year, Tom and his former wife (Judith Smith) and their children moved to California where he completed his residency at Santa Barbara Cottage Hospital. In 1985, he and his partners joined forces with Sansum Clinic where he would practice for the remainder of his career. In that same year, Tom married his current wife Jennifer Allen Hamilton. After 44 years of practicing medicine, Tom retired in 2014. His work was truly rewarding; he had the pleasure of treating multiple generations and watching his young patients grow up and start families of their own. Family was Tom’s top priority, both his immediate and extended family. He regularly traveled back to Evansville, Indiana to attend annual family reunions and catch up with longtime friends. Raised as a religious man, Tom found joy and community being a member of Santa Barbara Hope Church. It is incredible to reflect on how many lives Tom impacted in a positive way; he had this way of making others want to be a better version of themselves. Tom was preceded in death by his mother Thelma and sister Betty. He is survived by his siblings Bob, Allen, John, Margaret, and Judy. Tom is survived by his loving wife of 34 years Jennifer, his four children Michael (daughter in-law Nancy), Angela, Matthew, Evan, and three granddaughters — Austin, Jordan, and Madison. Adapted from the Santa Barbara Independent

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In Memoriam

GEORGE JOHN HIESTER, MD

1929-2020 George was born on November 15, 1929, in Seattle, Washington. He graduated from University of Washington Medical School in 1954. He then served as a doctor in the Air Force stationed at Larson Air Force Base, Moses Lake, Washington. In 1958 he moved to Santa Maria where he opened his family medical practice and continued practicing medicine for over 60 years. He delivered over 3000 babies and took great pride in taking care of multiple generations of families. His care for each one of his patients was personal and genuine. He was the true definition of a family doctor. Being a doctor was his life and it brought him much joy. George was an avid pilot and loved flying planes, especially his Piper Twin Comanche. He loved windsurfing, sailing, water skiing, and mountain biking with his late brother Carl. He enjoyed barbecuing a Santa Maria tritip or eating a good In-N-Out Burger. George loved traveling with family and friends. He was always learning new computer technology. George was funny, a great story teller and was loved by all that knew him. He was always just a phone call away, ready to listen, and he truly cared. Everyone in his life knew how much they were loved. At heart, George was a healer of people and things. Dr. George Hiester is survived by his loving wife of 43 years, Mary; children Marty Hiester, Jill Kennedy, Jan Hiester, Rand Hiester and Jason McGinnis; along with grandchildren Rebecca Orosco, Matthew Kennedy, Michael Orosco, and Brandon McGinnis. Also his devoted dogs Bailey and Princess. Adapted from the Santa Maria Times

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LAWRENCE LEO LUAN, MD

1924-2020 A descendant of a long line of scholars, Lawrence was born in Jinan and grew up in Qingdao, China where his father worked as Director of the Qingdao (Tsingtao) – Jinan railroad. Lawrence’s life in Qingdao, a peaceful seaside town in China, was interrupted by war and foreign occupation during the World War II era. Through these turbulent times Lawrence continued his education, following his school as it constantly relocated across China to regions that were free from occupation. In August 1943, Lawrence became a student volunteer in the Chinese Army, ordered to India and Burma, to fight the Japanese. There he was assigned to the Chinese First Army where he served as a medic and liaison to the U.S. forces. Having survived the chaos and pain of war, loss and separation, Lawrence and his future wife Barbara left China for the last time in November 1949 bound for Hong Kong. After months of insecurity in Hong Kong, they obtained visas for America where Lawrence managed to secure a second year slot at Loyola University Stritch School of Medicine. There he continued the medical training interrupted by the Japanese and Communist invasion. He supported his family as a taxi driver, studying when and where he could. After completing his training, Lawrence moved his young family to Albuquerque, New Mexico. Ultimately, the draw of a climate similar to his hometown would bring him to Santa Barbara where he and his family have lived for over 50 years. Lawrence will be lovingly remembered by his wife of 70 years, Barbara, and his children, Diana, James, and Michael, and daughter-in-law Ya-Ping. He will also be forever missed by his grandson, Patrick. Adapted from the Santa Barbara Independent

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In Memoriam

In Memoriam JAMES WILLIAM SHAW, MD

1939-2021 He was born in Washington, DC to James and Sylvia Shaw. He followed in his father’s footsteps and became a physician after attending Eastern Michigan University and graduating from University of Michigan Medical School. He moved to Los Angeles for his internship, residency, and fellowship at L.A. County/ USC Medical Center. While in Los Angeles, he met his wife Patti, who he was happily married to for 54 years. Daughter Kristin was born in 1969. After moving to Santa Barbara in 1973, he set up a private practice as an internist/ endocrinologist. Son Mark was born in 1974. He was a well-respected physician in Santa Barbara for over 30 years. He was president of the Santa Barbara County Medical Society and a member of the Santa Barbara Yacht Club and his beloved WLPA cycling club. Jim was a life-long avid outdoorsman, enjoying backpacking, fishing, sailing, skiing, cycling and golf. Woodworking was another passion of his, it gave him such joy making furniture in his workshop for friends and family. He had a generous heart and was always willing to help a friend in need. He loved being with his children and grandchildren in San Francisco and Marin. He is survived by his wife Patti, daughter Kristin (Jim), son Mark (Kate), grandchildren Madison, Alexander, Scottie, and Ryan, sister Sandra, and sister-in-law Ginny Fraser (Stu). Adapted from the Santa Barbara Independent

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LOUIS MATTHEW TEDONE, MD

1923-2021 Lou was born in Brooklyn, New York in 1923. He was the proud middle son of immigrants from Italy. After attending only two years at Fordham University, Lou was admitted to New York Medical College because the Navy needed doctors for World War II. He graduated in 1947, interned at St. Catherine Hospital, and did his pediatric residency at St. Catherine’s and Lutheran Hospital until 1951, both in Brooklyn. In 1949 he married Grace DePalo, another child of Italian immigrants. Because of the Korean War, this time, it was the Army that needed doctors. Lou enlisted as an officer so he wouldn’t be drafted as a private. He became the camp pediatrician at Camp Roberts from 1951 to 1953. Lou realized that practicing pediatrics in San Luis Obispo was preferable to Brooklyn. Edison French hired him in 1953 to become the first pediatrician in San Luis County. Lou worked for the French Clinic from 1953 to 1977, in solo practice until 1986, then with the Ekegren, Tedford, and Patterson Group for two more years. Upon his complete retirement, he made mozzarella for his daughter’s Shell Beach store, DePalo and Sons. Lou was an active community volunteer and involved with numerous causes. He received a Lifetime Achievement Award from the San Luis Obispo Community Health Foundation. In addition, the French Hospital Medical Center Foundation established the Dr. Louis M. Tedone Humanitarian Award to

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In Memoriam

be given annually to a deserving community member. Lou, of course, was the first recipient. He is predeceased by his parents Grace and Matteo, his brothers Frank and Nat, daughter Elissa, and wife Grace. He is survived by his children Gracie (Richard Manderscheid), Bob (Sheila), Bruce (Lee), Marisa (Kelly Teel), Matthew (Marianne), Andrea (Scott Williams), Joe (Kathy), Martin (Tracy), and Teresa (Tom Goossen); also, twenty-two grandchildren and fourteen great-grandchildren. Adapted from the San Luis Obispo County Tribune

PAUL ZETTAS, MD

1927-2020 Dr. Zettas was born in Chicago, IL, to Lillian and Gust Zettas. From the age of seven, he knew he wanted to become a doctor. After one year of college, he was called to serve with the U.S. Army in occupied Japan, just after WWII. He returned to finish college and graduated from the University of Illinois Medical School Chicago in 1953. He completed his residency in Orthopedic Surgery at Cook County Hospital in Chicago and at Boston Children’s Hospital. During his residency, he met and married Eugenia (Jenny) Demos, the love of his life. They moved back to Illinois to start their family, and together they had three daughters and were

Spring 2021

happily married for 65 years. In 1977, Dr. Zettas decided to return to California and join his brother, the late James Zettas, MD, to form Zettas Orthopedic Medical Group in Fresno. In 1988, Paul and Jenny moved to Santa Barbara to retire and truly enjoy California living. But within the year, he came out of retirement and joined the orthopedic team at the Sansum Clinic until he retired again in 2004. Paul’s true passion became tending to his orchard and nurturing his carefully chosen varieties of flowers, plants, and fruit trees. When he wasn’t in the garden, he was likely to be found on the tennis courts with his group of friends, affectionately called “the Grumpy Old Men.” Most evenings, he played the piano and sang a beautiful tune. Dr. Zettas is survived by his wife, Eugenia; three daughters Carol Weill (Michael), Pamela Perlman (Ed), Christine Di Filippo (Jim); and his two sisters-in-law Patricia Zettas and Bertha Patsavas. Paul was the proud Papou of four grandchildren, Evan, Scottie, Paul, and Lauren. Adapted from the Santa Barbara Independent and Fresno Bee

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