Central Coast Physicians Fall 2016

THE CENTRAL COAST RESPONDS TO

FALL 2016

With Great Pleasure We Introduce Our Newest Vascular Surgeons

Kevin M. Casey, M.D.

Dr. Kevin Casey completed his general surgery residency as Chief Resident at Ochsner Clinic Foundation in New Orleans, Louisiana. He then fulfilled his fellowship in vascular surgery at Stanford University Medical Center and is board certified by the American Board of Vascular Surgery.

Sara J. Runge, M.D.

Dr. Sara Runge completed her general surgery residency at the University of California, San Francisco. She then fulfilled her vascular surgery fellowship at the University of Florida.

C. SHAWN SKILLERN, M.D. I LI SHENG KONG, M.D. I SYDNEY S. GUO, M.D. I EDWARD N. LI, M.D. I KEVIN M. CASEY, M.D. I SARA J. RUNGE, M.D.

Our physicians specialize in minimally invasive and precision endovascular techniques for peripheral arterial disease, abdominal aortic aneurysm, carotid arterial disease, varicose veins, dialysis access and more.

www.WestCoastVascular.com Phone: 805-643-3330 I Fax: 805-643-3331 We have offices in Ventura, Oxnard, Santa Barbara & Lompoc 2

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Fall 2016

VOLUME 1 • FALL 2016

{FEATURES}

7 8 11 14 16 20 30 34 36 Fall 2016

2017 SLATE OF OFFICERS SUMMER SOCIAL PHOTOS MEET VANESSA DOCTORS TREATING DOCTORS UCSB STUDENT UPDATE ZIKA VIRUS

{DEPARTMENTS} 10 CLASSIFIEDS 12 MEN’S HEALTH: THE Y CHROMOSOME 18 RISK TIP: RANSOMWARE ATTACKS 28 PUBLIC HEALTH

POLST UPDATE

38 NEW MEMBERS

YOUR WEBSITE IS SO 2007

39 IN MEMORIAM

MACRA

CENTRAL COAST PHYSICIANS

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Letter From The Executive Director

CHANGE IS ALL AROUND US Welcome to the first issue of Central Coast Physicians. This magazine is one of the many changes at the Central Coast Medical Association. Personally, I love change since with change comes opportunity.

Approximately two year ago physician leaders in San Luis Obispo and Santa Barbara DANA GOBA counties had the wisdom to join forces and become one stronger medical association. CCMA was born upon this merger of two great medical organizations, the San Luis Obispo County Medical Association and Santa Barbara County Medical Society.

One year ago, I was given the opportunity to work with the wonderful physicians in our community following the retirement of Lisa Reich, who joined the organization after Sondi Jacoby retired.

In addition, we have a new staff position, Physician Relations Manager, at CCMA. Read about Vanessa in this issue and how she’s here to help physicians and their medical practices.

The healthcare arena is transforming as well: MACRA, CURES, electronic health records, End of Life Option Act, to name a few.

CCMA is here to support our members through these times. Contact us with your practice management, legal, and other questions. We’re here for you.

Together we will work through the changes and be more successful than ever.

Best,

Dana Goba Executive Director Central Coast Medical Association

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PRESIDENT Charity Dean, MD, MPH PRESIDENT ELECT David Dodson, MD SECRETARY Jennifer Hone, MD TREASURER Joseph Schwartz, MD IMMEDIATE PAST PRESIDENT John Sawyer, MD DIRECTORS Daniel Berger, MD; Jonathan Berkowitz, MD; Philip Delio, MD; Kevin Ferguson, MD; Douglas Jacobson, MD; Bindu Kamal, MD; Douglas Murphy, MD; Juan Reynoso, MD

MEDICAL ASSOCIATION STAFF EXECUTIVE DIRECTOR Dana Goba PHYSICIAN RELATIONS MANAGER Vanessa Campos BOOKKEEPER Patrick Carpenter CME COORDINATOR Julie Staff CMA HOUSE OF DELEGATES REPRESENTATIVES Sharon Basham, MD; Edward Bentley, MD; David Dodson, MD; Jennifer Hone, MD; John Sawyer, MD; Joseph Schwartz, MD ALTERNATES Sam Ahmad, MD; Charity Dean, MD, MPH; Christopher Lumsdaine, MD; Douglas Murphy, MD; Jenni Nix, MD; Steven Yao, MD CENTRAL COAST PHYSICIANS MAGAZINE EDITOR Charity Dean, MD, MPH MANAGING EDITOR Dana Goba CREATIVE DIRECTOR Sherry Lavone Design CONTRIBUTING WRITERS Ali Javanbakht, MD; Craig Musgrave; Dana Goba; David Dodson, MD; Edwin Feliciano, MD; Elizabeth Schwyzer; Jeanne West; Mary Ferris, MD; Robert W Wong, MD; Susan Klein-Rothschild CONTRIBUTING PHOTOGRAPHER Elizabeth Schwyzer SUGGESTIONS, story ideas, or completed stories written by current Central Coast Medical Society 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 Magazine 5350 Hollister Ave, Ste A4 Santa Barbara, CA 93111 T 805.683.5333 F 805.687.2871 E editor@sbmed.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 advertising@sbmed.org.

Fall 2016

Do you know What, When and How to Report Child Abuse?

FREE ONLINE COURSE! Course developed by the Child Abuse Prevention Center









Approved for 1.25 AMA PRA Category 1 Credits™ Approved for 1.25 CE credits

ALL healthcare providers (MD, DO, RN, PhD, LCSW, MSW) are encouraged to take this valuable course! 

Course available 24/7

Register NOW at: http://www.imq.org/education/caprrc.aspx

The Central Coast Medical �ssocia�on�s president

Charity Dean, MD, MPH cordially invites you to the

TÇÇâtÄ `xÅuxÜá{|Ñ `xxà|Çz Keynote Speakers

Ruth E. Haskins, MD

Lee T. Snook, Jr, MD

President �a�ifornia �edi�a� �sso�ia�on

Speaker of the House �a�ifornia �edi�a� �sso�ia�on

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6:00 pm Recep�on 7:00 pm Dinner & Program

633 E Cabrillo Blvd, Santa Barbara

6:00 pm Recep�on 7:00 pm Dinner & Program

100 Madonna Rd, San Luis Obispo

RSVP must be received by November 10 to guarantee a�endance.

805.683.5333 sbcms@sbmed.org

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CENTRAL COAST PHYSICIANS

Fall 2016

2017 CCMA Officer Slate The following candidates are presented by the Nominating Committee and Board of Directors.

Elections will be conducted at the Annual Membership Meeting in Santa Barbara.

BOARD OF DIRECTORS EXECUTIVE COMMITTEE

President President-Elect Secretary Treasurer DIRECTORS

Director Director

REMAINING IN OFFICE

Immediate Past President Director Director Director Director Director Director

David Dodson, MD Jennifer Hone, MD Dan Berger, MD Joe Schwartz, MD

1/17 - 12/17 1/17 - 12/17 1/17 - 12/17 1/17 - 12/17

Lisa Ercolini-Bhatia, MD Samira Kayumi-Rashti, MD

1/17 - 12/19 1/17 - 12/19

Charity Dean, MD Jon Berkowitz, MD Phil Delio, MD Doug Jacobson, MD Bindu Kamal, MD Doug Murphy, MD Juan Reynoso, MD

1/17 - 12/17 1/15 - 12/17 1/15 - 12/17 1/15 - 12/17 1/16 - 12/18 1/16 - 12/18 1/16 - 12/18

DELEGATION TO THE CMA DELEGATES

Delegate Delegate Delegate Alternate Delegate REMAINING IN OFFICE

Delegate Delegate Delegate Alternate Delegate Alternate Delegate Alternate Delegate Alternate Delegate Alternate Delegate

Fall 2016

David Dodson, MD Jennifer Hone, MD Joe Schwartz, MD Doug Murphy, MD

7/17 - 6/20 7/17 - 6/20 7/17 - 6/20 7/17 - 6/20

Sharon Basham, MD Ned Bentley, MD John Sawyer, MD Sam Ahmad, MD Charity Dean, MD Chris Lumsdaine, MD Jenni Nix, MD Steven Yao, MD

7/16 - 6/19 7/15 - 6/18 7/16 - 6/18 7/16 - 6/19 7/15 - 6/18 7/15 - 6/18 7/16 - 6/19 7/16 - 6/19

CENTRAL COAST PHYSICIANS

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summ

mer Fall 2016

Social THANK YOU TO EVERYONE WHO ATTENDED THE SUMMER SOCIAL AT SUNSTONE WINERY.

CENTRAL COAST PHYSICIANS

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CL

DS

F I S IE S A

WANTED

Established Santa Barbara surgeon looking for physician(s) with existing office space to share. If interested please call 805.452.1899.

OFFICE SPACE AVAILABLE

POSITIONS AVAILABLE

Seeking experienced MEDICAL ASSISTANT for busy urology office.

Successful candidate should possess demonstrated ability to effectively communicate with patients; accept work direction from multiple sources; manage patient flow, including pre-visit preparation, assisting with patient visit, and post-visit duties; maintain confidentiality at all times. Previous experience as medical assistant preferred. mrs_cyn@yahoo.com The COUNTY OF SAN LUIS OBISPO Law Enforcement Medical Care Unit at the County Jail is recruiting for a contract Medical Doctor to perform assessments, establish medical diagnoses, order and evaluate diagnostic tests and medications, and manage follow-up care for a jail population.

For more information, go to www.slocounty.ca.gov and click “Career Opportunities”.

The COUNTY OF SANTA BARBARA is looking for five Staff Physicians to fill critical roles in our Public Health’s Primary Care and Family Health Division.

These physicians will collaborate with a team of physicians, nurses and other staff providing clinical services in our expanding Federally Qualified Health Clinics throughout the County. www.sbcountyjobs.com SANSUM CLINIC is the largest and oldest multi-specialty group between San Francisco and Los Angeles with over 200 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/physicianprovider-job-opportunities.

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Large OFFICE DOWNTOWN on State Street available for sublease 1-3 days per week in Historic Landmark Professional Building. Beautifully and newly furnished, tall ceilings, Riviera views, equipped with waiting room, Wi-Fi, light alert, a/c, alternate exit/entrance, and access to large conference room.

Perfect for consultation, therapy, or mental health professional.

Reasonable rates.

Ron, 805.962.0266

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

Fall 2016

MEET VANESSA New Physician Relations Manager for Members

practice and resumes are provided complimentary to members

Vanessa Campos has joined the Central Coast Medical Association as Physician Relations Manager where she will be working with local physicians. Vanessa has more than 12 years’ experience in the medical field, and most recently she was the Office Manager and Patient Care Coordinator for a busy medical practice. Contact her regarding any of the member benefits, including those provided through CCMA:

You can also contact Vanessa regarding benefits provided through the California Medical Association including:

Referrals: approximately 1,000 phone calls are received annually seeking physician referrals Low-cost education programs: trainings, such as Medicare updates and OSHA, are provided annually at a reduced rates to members

Promoting the science and art of medicine, the care and well-being of patients, the protection of the public health and the betterment of the medical profession.

Connecting with colleagues: multiple events are held each year to give members an opportunity to connect with fellow physicians Mailing labels: members receive complementary physician address labels Resumes: CCMA collects resumes of people who can help your

Practice assistance: highly trained economic advocates with expertise in physician reimbursement and medical business issues are available to provide one-on-one help to improve your bottom line Legal help: provides free assistance with legal questions regarding human resources, medical, regulatory, and other issues Educational programs: on-demand webinar topics include contract negotiations, reimbursement 101, CURES, End of Life Option Act, and MACRA Group buying discounts: members receive deep discounts on everything from magazines and office supplies to insurance products

Vanessa can be reached at 805.683.5333 or vcampos@sbmed.org.

CONTRACT RENEGOTIATIONS Making Your Business Case When submitting a request to open up a contract renegotiation discussion, best practice is to present a “business case” as to why the payor wants to keep your practice in the network. Failure to present a business case often results in a quick reply from the payor indicating that they are not in a position to renegotiate at this time. To prevent the “auto-reply,” the California Medical Association (CMA) suggests you be thoughtful in your renegotiation request.

To help physicians prepare for negotiations or renegotiations, CMA has created a contracting resource. CMA members can obtain a free copy at www.cmanet.org/resource-library or by calling 800.786.4CMA.

Fall 2016

CENTRAL COAST PHYSICIANS

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David Dodson, MD > Y Chromosome

The

BY DAVID DODSON, MD

Chromosome Carry At Your Own Risk

Traditionally, men like to think of themselves as the stronger sex. This is

manifestly not the case when it comes to health and longevity, although the

gap has narrowed somewhat since 1979 when women in the US enjoyed an

average life expectancy 7.8 years longer than men. Currently, US women’s life

expectancy is 4.8 year longer than men, placing American men’s life expectancy 25th in a ranking of 30 countries; US women are tied with Poland for 27th place.

Decreases in coronary disease death rates in men and increases in lung cancer mortality in women account for much of the narrowing of the gap.

According to the CDC’s National Center for Health Statistics annual publication Health, United States (source of the above statistics), men have higher mortality rates for all 12 leading causes of death with the single exception of Alzheimer’s disease – because we don’t live long enough to get it as often as women do. Mortality rates per 100,000 per year range from very slightly higher for stroke to almost 4 times the risk for homicide – 8.0 for men vs 2.1 for women, almost 3 times higher for AIDS – 3.0 vs 1.1. For CAD mortality rates are 133.5 for men compared with 71.6 for women, for cancer 192.9 for men, 138.1 for women.

These figures raise the question: why is it that the Y chromosome appears to be so risky? One explanation is risk, i.e. risky behaviors. This would include both recklessness such as fast and aggressive driving, and men’s predominance – once to the point of exclusion, less so now – in so-called death professions such as deep sea fishing, mining, combat soldiering,

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etc. Another factor is that more men than women are cigarette smokers. Violent deaths from both homicide and suicide are also much more common in men than women; tragically the suicide rate for men is 20.7 per 100,000 compared with 5.8 for women making it the tenth leading cause of death for men.

Ironically, despite their much poorer health statistics, men are far less likely to visit their doctor and to have a primary care provider than women. Much of this is culturally driven.

Traditionally men are raised to be breadwinners and a man with a high income is considered to be a “catch”. This ethos tends to make men feel they should be at work, not at the doctor’s office, even that having a check-up is unmanly or slacking off. When they do go, they are likely to find waiting rooms populated primarily by women with reading materials to reflect it: this month’s Vogue or Good Housekeeping, and an old, tattered Sports Illustrated or Outdoor magazine if one at all. Not to mention office hours seldom allow for men to be seen in the

Fall 2016

evening or weekend, so if they work full time they need to get time off if they are to be seen, which many either can’t or won’t. Women tend to be a lot more comfortable with the medical environment, which is normalized for them when they begin to receive regular GYN care for birth control and obstetrics, an entrée men do not have.

If men wish to improve their health, we could start by learning from women. Women are smart advocates for their own health.

When Congress cut funding for prostate cancer research, who noticed? If they did that for breast cancer, women would be in the streets and politicians would be voted out of office, which is another story altogether: women, being smarter than men, out-vote men. This is why the National Institutes of Health (NIH) has an Office of Women’s Health. Several years ago I took a resolution to the American Medical Association to advocate for the creation of an Office for Men’s Health at the NIH. The good news is that the resolution passed and became AMA policy. The bad news is that Congress yawned, did nothing, and a bill calling for one went nowhere. I am very glad for women there is an Office for Women’s Health and I wish it every success. But given the facts discussed above – from the government’s own data – it seems the potential benefits of a corresponding Office for Men’s Health is obvious.

The physicians and medical staff at Sansum Clinic are pleased to work among the many respected medical professionals on the Central Coast.

1-800-4-Sansum • www.sansumclinic.org

Ad3.final.indd 1

Fall 2016

10/4/16 4:25 PM

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Charity Dean, MD > Physicians Treating Physicians

How Physicians Treat One Another Matters

Charity Dean, MD

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We were enjoying a pajamas-and-popcorn family evening during Christmas break last year when I got a call from a public health nurse in Disease Control. She (and lab staff) had stayed late on this holiday night to follow up on a Tuberculosis (TB) lab test, knowing the patient was scheduled for surgery the next day. I was relieved to hear the results and wanted to communicate them immediately to the surgeon, whom I did not personally know. Having been involved in numerous TB contact investigations after a surgeon unknowingly brought an infectious TB patient into the operating room, I was sure he would be relieved to hear the good news, thankful for Public Health’s diligent after-hours follow-up, and wish me and my family a very happy holiday.

After tucking the kiddos in front of The Grinch and finding a quiet corner of the house, I pulled up the patient’s lab results and dialed the surgeon’s cell phone.

About two sentences into cheerfully communicating the good news about his patient’s TB results, I was interrupted by what can only be described as a crescendo of illogical mansplaining1. He launched into yelling how dumb I must be to try and tell him anything about his own patient, how he had already solved “the tuberculosis thing”, how nurses should not be calling his cell phone, and some incoherent (and incorrect) facts about the sensitivity of AFB sputum smears. When he finally took a breath, I calmly explained again that this was Doctor Dean, and I am the TB Controller and Health Officer, trying to help prevent his OR case from being canceled by sharing critical late-breaking lab results. Again I was interrupted by a crescendo of narcissistic spewing even after he understood I was a physician.

Finally, I’d had enough. During his next breath, I told him to either speak professionally or I was going to hang up. Eventually he calmed down enough to listen and participate in a conversation. When we ended the call, I sat silently listening to the jingly “You’re a mean one, Mr. Grinch. . .” floating up from our cozy family room below. I smiled and shook my head, reflecting that I hadn’t been chewed out by a surgeon like that since I was a surgical resident 10 years prior.

The problem for this surgeon, however, is that I wasn’t his surgical resident and I wasn’t his nurse. I was his colleague; the head official over Disease Control, a statewide expert in Tuberculosis, and had authority to put his patient in mandatory isolation. I was also a referring physician with deep roots in this community where relationships matter. And two weeks prior, I had become President of the Central Coast Medical Association.

Fall 2016

My professional experience in this community over the past 11 years has led me to believe that relationships are critically important to our success as physicians. In my role as Health Officer, positive working relationships are my most valued asset. On a daily basis I am communicating and negotiating with my colleagues across a spectrum of issues.

Sometimes we disagree—even strongly disagree—but we find ways to do it without being disagreeable. At the end of the day, physician leaders understand that none of us practice medicine in a vacuum.

We do it together, through referrals, co-management, and communication among healthcare partners and support staff.

In the pre-internet, pre-ACA, feefor-service era, where solo and small practice docs flourished without fear

of extinction or on-line reviews, hotheaded tirades were unlikely to affect the bottom line. A poor bedside manner and grumpy disposition may even have been a physician’s proudest attribute. But today, under the massive informationsharing capability of the internet and the changing landscape of healthcare delivery post-ACA, bad behavior can have a very real business cost. A physician’s attitude toward their colleagues and community is, in fact, a business decision. Giving patients fodder for harmful on-line reviews, alienating referring docs, and getting labeled as a sand-thrower in the proverbial sandbox of medicine are poor business decisions, indeed.

Back in the office the next day, reflecting on how physicians treat one another and the larger impact it has on their success as small business owners,

I had a growing curiosity about this particular surgeon and phoned a primary care colleague for some perspective. “Oh yeah,” she chuckled. “I stopped referring to him years ago. None of us do,” she said in reference to her medical practice partners.

Thanks to a healthy perspective and well-oiled sense of humor, I really have only two take-away feelings about the interaction that day: sadness, for how miserable it must be to navigate one’s medical career slinging hostility and aggression, and gratitude, for the universe unexpectedly reminding me to be impeccable with my own words and kind in my own actions. Physician leaders have many opportunities to set examples— let’s make them positive ones.

Wikipedia definition, Mansplaining: “Mansplaining covers a heterogeneous mix of mannerisms in which a speaker’s reduced respect for the stance of a listener…appears to have little reason behind it other than the speaker’s assumption that the listener or subject, being female, does not have the same capacity to understand as a man.”

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STUDENT UPDATE UCSB Student Health administers an emergency medical fund, generously donated by local medical professionals

BY MARY FERRIS, MD, EXECUTIVE DIRECTOR ALI JAVANBAKHT, MD, MEDICAL DIRECTOR EDWIN FELICIANO, MD, BEHAVIORAL HEALTH DIRECTOR UCSB STUDENT HEALTH

This fall, the University of California, Santa Barbara (UCSB), enrolled approximately 4,995 new freshmen and 2,050 transfer students, an increase of 1,031 additional students compared to last year, adding up to a total of 24,650 students. California residents make up 84 percent of the entering freshmen, and 86 percent of new transfer students (19 percent of which come from Santa Barbara City College and another 29 percent from other local community colleges).

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The campus was proud to enroll 40 percent of freshmen and 48 percent of new transfers who are the first in their families to attend college. UCSB has been named a “Hispanic-Serving Institution” for having a Hispanic enrollment over 25 percent, and is the only HSI that is also a member of prestigious Association of American Universities. UCSB also has a total enrollment of approximately 10 percent international students, with the majority coming from Asia, both in graduate and undergraduate studies.

Fall 2016

Financial need is a pressing problem for UCSB students, with 43 percent qualifying for maximal assistance. A new trend resulting from the Affordable Care Act changes to the Medicaid eligibility criteria has resulted in almost 3,000 UCSB students enrolled in Medi-Cal, most often based in their home counties. The UCSB student health insurance PPO plan (sponsored

by Aetna) is chosen by 45 percent of students, with the rest using other plans. We verify that every student has health insurance meeting minimum criteria, which is a requirement of attendance at all UC campuses.

Fall 2016

UCSB Student Health administers an emergency medical fund, generously donated by local medical professionals, which provides grants of up to $200 to help students meet deductibles and copays that might otherwise prevent them from seeking specialty care. Students can be referred to the Social Workers and Insurance Office to help them manage their bills or other stresses.

The Student Health Service at UCSB is fully accredited and offers a “patientcentered medical home� for the 24,000 total students, 9,500 of whom live in University-owned housing. New students

are assigned to a primary care provider to encourage continuity for better health and providers are organized into care teams. The staff includes family and internal medicine physicians, psychiatrists, social workers, and midlevel practitioners, as well as an alcohol and drug program for counseling and preventive services. We are eager to work with local medical providers to coordinate care and obtain the best possible outcomes for our students.

Please do not hesitate to contact Student Health for any issues relating to UCSB students.

CENTRAL COAST PHYSICIANS

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RANSOMWARE ATTACKS HIPAA Burden Falls to the Hospital or Medical Practice

BY CRAIG MUSGRAVE SENIOR VICE PRESIDENT, INFORMATION TECHNOLOGY • THE DOCTORS COMPANY

The bar has been raised on HIPAA and ransomware attacks.

Under its recently released guidance, the Department of Health and Human Services (HHS) now presumes that a ransomware attack compromises electronic protected health information (ePHI)—unless the HIPAA-covered entity can prove otherwise.

Prior to this new guideline, if you determined on your own that there was no breach, no action was needed on your part.

HHS would have to prove that the ransomware attack had compromised ePHI. But now that burden of proof has changed—it’s now your responsibility to prove that data was not compromised, including patient records, credit card data, and employee records. If you have a breach, or can’t prove that you did not,

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you must complete the HIPAA notification procedures and may face fines. You may also be fined if it’s shown that your practice was not HIPAA compliant before the attack.

Large healthcare systems and hospitals with sophisticated technology systems may have an easier time meeting this burden of proof. Firewalls can track the traffic of the cyber criminals and record what data they had access to, how long they spent in the system, and what data they extracted. Small practices without sophisticated systems or firewalls may have to hire a forensic computer firm in order to prove that a breach of their systems did not occur.

Ransomware remains a major threat for practices and hospitals—not only do over 50 percent of all cyber attacks occur in healthcare, but there have also been 4,000 daily

Fall 2016

Ransomeware > HIPAA Burden

ransomware attacks since early 2016, which is a 300 percent increase over the 1,000 daily attacks in 2015.

Ransomware attacks exploit technical and human weakness to gain access to a healthcare organization’s system and deny the organization access to its own data.

What You Should Do To Prevent an Attack

monitoring activity within your stored data.

Understand your options if the cloud provider is hacked or your data is lost.

Virtually all cloud service providers require a user to sign an agreement that contains a terms of service provision.

In most cases, these agreements provide that the user has very little, if

OVER 50 PERCENT OF ALL CYBER ATTACKS OCCUR IN HEALTHCARE

Encryption used to be the standard method to prevent breaches and protect your practice, but that has also now changed. Encryption does not stop ransomware attacks—if a cyber criminal gets access to your system, encryption will not stop the attack.

In addition, encryption is no longer sufficient to prove that a breach has not occurred during a ransomware attack. While encryption of all laptops, desktop computers, and mobile devices remains important to overall security, practices and hospitals also now need to take additional steps: Small practices should migrate their systems—both software applications and data—to the cloud. Cloud vendors have implemented security measures that most smaller practices won’t be able to implement and maintain. Be sure to fully vet your cloud storage vendor: Are the vendor’s security standards appropriate? You have to research each vendor you choose. Make sure the company has a good reputation and solid security policies. You are entrusting the provider to store your information, so the extra time spent researching and comparing providers and their security practices will pay off in the long run.

How much data will you be storing?

Many companies charge by the amount of storage you use, so understand what your needs are before choosing a vendor. Ensure the vendor can handle

Fall 2016

the amount of data you would like to move to the cloud.

Ensure your data is encrypted when being uploaded to or downloaded from the cloud. This is also your responsibility. Make sure your browser or app requires an encrypted connection before you upload or download your data. Also ensure all

devices that contain ePHI (laptops, desktops, thumb drives, and centralized storage devices) are encrypted.

Make sure your data is encrypted when stored in the cloud. This is perhaps the most important consideration. Data protected by law, such as medical information or personal identifiers, should never be stored in the cloud unless the storage solution is encrypted. Only selected members of your organization should be able to decrypt the data, and your organization should create policies detailing under what circumstances information can be decrypted.

Determining whether the stored data will be encrypted requires a careful review of the specific terms of service within your agreement with the cloud service provider. Many cloud service providers store data on a cloud server with no encryption, meaning anyone who has (or can get) high-level access to that server will be able to read your files.

Understand how access is shared in your cloud folder. Many cloud storage providers allow you to share access to your online folders. Be familiar with the details on how that sharing works.

Can the user read-only or can the user edit the file? Will you know who the last person to edit a file was? Awareness of who has access and how is critical to

any, remedy if a hack or a loss of data occurs. Pay attention to what rights you have given up and make sure you are comfortable with doing so.

If you cannot store data in the cloud, consider working with a computer forensic firm to strengthen your security and investigating capabilities.

Provide security awareness for all employees. Over 80 percent of attacks are made possible by human error or human involvement. Train staff members to avoid downloading, clicking on links, or running unknown USB on computer systems.

Block the malware at the firewall by using intelligent firewalls to stop the malware from downloading.

Install intrusion detection software to monitor illegal activities on computer networks.

Stop the malware from executing on desktop computers by installing application whitelisting software, antivirus, or anti-malware.

Perform regular system backups.

Ensure that critical systems and business data are backed up—even backed up hourly for critical systems.

Test that the backup restore process works.

Perform penetration testing on a regular basis to determine any existing vulnerabilities that should be patched.

CENTRAL COAST PHYSICIANS

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THE CENTRAL COAST RESPONDS TO

BY ELIZABETH SCHWYZER

FROM LITTLE-KNOWN VIRUS TO PUBLIC HEALTH CRISIS, ZIKA HAS COME AS A SURPRISE

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Fall 2016

Fall 2016

CENTRAL COAST PHYSICIANS

21

Most of what we do is clearing up misinformation

Deep in the forests of Uganda the air is cool and humid, and the high whine of mosquitoes is constant. The year is 1947, and scientists with the Rockefeller Foundation have come to this region, whose name means “overgrown,” to study a mosquito-borne virus that has long plagued humans: yellow fever. When they discover a febrile rhesus monkey in the forest canopy, they transport the animal to their laboratory in Entebbe. There, tests reveal not yellow fever but an unfamiliar virus. They name it after the forest where it was found: Zika.

Five years later, the first human cases of Zika virus are detected in Uganda and Tanzania. Yet over the next half a century, evidence of Zika in humans is extremely rare; only 14 cases are documented worldwide. Compared with yellow fever and other mosquito-borne viruses – among them malaria, dengue fever, chikungunya, and West Nile Virus – Zika remains a blip on the radar of infectious disease.

That is, until 2015.

In March of that year, Brazil notified the World Health Organization (WHO) of an illness characterized by a skin rash circulating in four of its northeastern states. By May, more than 7,000 cases had been reported, and laboratory tests confirmed the Zika virus. By the end of that year, the Zika outbreak had spread to Colombia, Cabo Verde, Suriname, Panama, El Salvador, Mexico, Guatemala, Paraguay, Venezuela, Honduras, French Guiana, Martinique, and Puerto Rico.

“The whole virus was a surprise,” notes Dr. Mary-Louise Scully, Director of the Sansum Clinic Travel and Tropical Medicine Center in Santa Barbara. She’s talking about Zika’s transformation from a little-known tropical disease with apparently mild effects to an international public health crisis.

Despite the fact that she specializes in infectious disease, a visit with Scully could get anyone in the mood for an international adventure.

Fast-talking, enthusiastic, and infectiously curious, Scully clearly understands the threat of the Zika virus. Yet she also sees the epidemic as a fascinating case of the way a virus can all but disappear, only to pop up again halfway around the world with renewed vigor.

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CENTRAL COAST PHYSICIANS

Fall 2016

A GLOBAL EPIDEMIC

For the past year, Zika has been dominating international headlines. That’s a lot of attention for a virus, particularly one that in most cases is relatively benign. For the majority of those who contract it, Zika is not a serious medical condition: only 20 percent of those infected become symptomatic at all. In those who do, the symptoms of Zika are similar to its Flavivirus relative, dengue, but often milder: fever, rash, joint pain, fatigue, and conjunctivitis, or bloodshot eyes. What’s made news of Zika go viral are the relatively rare but serious conditions that can result from an infection: microcephaly, a devastating birth defect in which a baby is born with an abnormally small head and insufficiently developed brain, and Guillain-Barré syndrome, a rare disorder in which the body’s immune system attacks the nerve cells causing weakness and paralysis. Most cases of Guillain-Barré syndrome are temporary, but some sufferers are left with lingering effects. Zika is not the sole cause of either of these conditions, but both the WHO and the Centers for Disease Control (CDC) say there is scientific consensus that Zika is linked to both conditions. There’s also some speculation that people who have been infected with dengue fever in the past may have a more severe reaction to the Zika virus.

In addition to these hitherto unknown side effects, the surprise of Zika has been in the fact that, unlike any other known mosquito-borne virus, it can be transmitted sexually. The virus can also lie dormant in semen for a period of months before being transmitted from one person to another.

There are only two species of mosquito known to be vectors of the Zika virus: Aedes aegypti (or yellow fever mosquito) and Aedes albopictus (also known as Asian tiger mosquito, so named for its black-and-white striped legs and body). Both are aggressive, day-biting insects, the same species that transmit dengue fever, yellow fever, and chikungunya. There is an effective vaccine for yellow fever, but there is no vaccine or treatment available for dengue, chikungunya, or Zika.

As of September 22, 2016, the WHO is reporting 56 countries and territories where there has been a Zika outbreak in recent months, 12 countries where person-to-person transmission of the virus has been verified, and 21 countries where Zika appears to have caused microcephaly in the babies of infected pregnant women. Nineteen countries have reported an increase in the incidence of Guillain-Barré syndrome since the outbreak of Zika.

Exact numbers ar hard to come by – it’s often impossible to determine whether infection resulted from a mosquito bite or from sexual contact, for example, or whether a specific case of microcephaly resulted from exposure to toxins or to a Zika infection. One thing that’s certain is that thus far, Brazil has been the hardest hit with microcephaly. Estimates for the total number of Zika-related cases in that country since the outbreak began range from 1,500 to 4,500 or more. Some studies suggest that as

Fall 2016

many as 13 percent of pregnancies infected by Zika in the first trimester may result in birth defects; others put that number as low as one percent.

Unlike many other tropical diseases transmitted by mosquitoes, Asia and Africa are not epicenters for Zika. In fact, up until August 2016, the only country reporting active transmission on those continents was Cape Verde in Africa. Yet in recent weeks, Zika has made an appearance in Asia. First, Singapore started reporting active transmission of the virus, then came the Philippines, and now several other South East Asian countries are reporting new cases, leading the CDC to suggest pregnant females avoid travel to 11 countries in the region. Zika is on the move yet again.

Still, the current hot spots of intense Zika transmission remain Central and South America, as well as the U.S. territory of Puerto Rico. In late July of this year, the United States joined the list when Florida’s Miami-Dade County confirmed active transmission of the virus. As of late September, 43 locally acquired cases of Zika had been reported in Florida. No other US states had reported local transmission, although every state in the union has documented travel-related cases: the national tally is

CENTRAL COAST PHYSICIANS

23

Zika Virus > Local Efforts

more than 3,500 and growing, with the majority of those in New York, Florida, California, and Texas.

Doctor Scully may have been surprised by the recent Zika outbreak, but not because she hadn’t been tracking the virus. She had watched Zika come and go over the years – an outbreak on the Micronesian island of Yap in 2007 was notable as the first time Zika had been identified outside of Asia and Africa, while a larger epidemic in French Polynesia in 2013 infected an estimated 20,000 people. Scully, who regularly advises Central Coast patients traveling internationally to take precautions against common mosquito-borne pathogens like malaria and dengue, was relatively unconcerned about Zika. Just two years ago, she helped a less experienced colleague of hers write up a travelrelated Zika virus case in New York, but declined the offer to appear as a co-author of the report, figuring few would read it.

“Now,” she notes wryly, “that report is everywhere.”

ZIKA ON THE CENTRAL COAST

One year ago, most physicians had never even heard of Zika virus. That was the case for Dr. Alex Soffici, an OB/GYN who directs Maternal Fetal Medicine at Santa Barbara Cottage Hospital and heads the Central Coast Perinatal Group.

“We all had to learn about it together,” he said of the virus.

Given that there is no cure for Zika, Soffici noted, the primary work of healthcare providers is to keep patients informed.

“The biggest impact we can have is to encourage patients to avoid traveling to areas with Zika,” he said. “For those who have been potentially exposed, we can offer testing. But most of our patients are not at risk. Most of what we do is clearing up misinformation.”

For the majority of Central Coast residents, the risk of Zika infection is low. To date, there have been just five cases of travel-related Zika identified in Santa Barbara County, and no cases reported thus far in San Luis Obispo County. There have been no cases of local mosquito-borne transmission of Zika virus anywhere in California, although cases of sexual transmission have been documented. Neither Aedes aegypti nor Aedes albopictus mosquitoes have been found in Santa Barbara or San Luis

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CENTRAL COAST PHYSICIANS

Obispo counties, though they have been identified in neighboring Kern County and 11 of California’s other 57 counties. In other words, although it’s important to stay informed about the virus and take precautions if traveling, there’s no cause for immediate concern for Central Coast residents.

At the same time, Soffici noted, “The status of Zika is changing on almost a daily basis. We are very fortunate not to have any Zika-carrying mosquitoes at this time, but this could change.”

That’s a fact David Chang knows well. As the general manager of the Mosquito and Vector Management District of Santa Barbara County, Chang’s job is to keep close tabs on the insects. The majority of the district’s work focuses on controlling the indigenous mosquito population, but given the risk of Zika, they’ve ramped up the hunt for invasive species.

“Our field staff know almost every puddle and pond in the county,” Chang said. “We’ve been placing traps in various locations around the county to try to find the needles in a haystack, so to speak.

We’re trying to protect people.”

Because San Luis Obispo County lacks a similar organization, Chang’s department and the Monterey County Mosquito Abatement District have been assisting them in the search for potential Zika transmitters.

But mosquitoes may not be the Central Coast’s biggest concern when it comes to the Zika virus. Dr. Penny Borenstein, Health Officer with the San Luis Obispo County Public Health Department, isn’t too concerned about bug bites – at least, not for now.

Instead, she worries that a pregnant woman from the Central Coast will become infected with the Zika virus while traveling, or will contract the virus from a partner who has been infected.

“We don’t have the vector mosquito in our county and are not anticipating local transmission in the foreseeable future,” Borenstein noted. “But I think it is likely that we will have travel-related cases.

Because of the significance of the birth defects, it is really important that the general population understands the nature of this virus and how to avoid it.”

The basic guidelines, Borenstein said, are that pregnant women and those attempting pregnancy should not travel to areas with known Zika transmission. If a woman is pregnant or attempting pregnancy and her sexual partner travels, they

Fall 2016

Our field staff know almost every puddle and pond in the county.

should avoid sex or use condoms.

Just how long these precautions should be taken is a matter of debate.

Current research suggests that the Zika virus lingers in semen longer than in other body fluids, but with studies still underway, much remains unknown about the virus’s persistence in saliva, urine, and vaginal fluid. Guidelines for how long to practice safer sex following Zika exposure are evolving. At this

Fall 2016

time, both the CDC and the WHO recommend that couples use condoms or abstain from sex for a period of six months following a partner’s return from an area with Zika, regardless of whether there were Zika symptoms. Both the CDC and the WHO also recommend that pregnant women whose partners may have been exposed to the virus during travel continue to practice safe sex for the duration of the pregnancy.

Pregnant women with an exposure history are being tested, but what about those who are considering or attempting pregnancy and want to be tested to rule out the possibility that they have been exposed to the virus? Unfortunately, noted Borenstein, not all of these requests can be accommodated.

“In San Luis Obispo County, we are using fairly stringent criteria before sending specimens to the state

CENTRAL COAST PHYSICIANS

25

Zika Virus > Local Efforts

laboratory,” she explained. “There is limited capacity for testing, and we want to test the highest risk patients.” Those who suspect they have been exposed to the virus and wish to be tested can consult with their physician or contact the Public Health Department directly. Patients are then interviewed to determine whether they meet the state’s specifications for testing. Those who do are generally pregnant women who have traveled to a region with Zika or who have had unprotected sex with a partner who did so, Borenstein explained. Testing must be done within 12 weeks of exposure, she added.

This is the first time in 50 years that we have identified a new infectious cause of birth defects.

It’s the first since rubella.

Experts estimate the earliest a vaccine could become available would be early 2018.

While there’s no reason to raise the alarm on the Central Coast, Borenstein said, there’s also “no question that Zika is a significant new health emergency globally.”

“This is the first time in 50 years that we have identified a new infectious cause of birth defects,” she noted. “It’s the first since rubella.”

MANAGING ZIKA

In the case of rubella, of course, a vaccine has been widely available since the late 1960s. But a vaccine for Zika is likely years away. In February of this year, President Obama requested $1.9 billion from Congress to combat the virus. On September 28, after months of delay, the Senate finally approved $1.1 billion to fund the federal response to the virus. Brazilian and American virologists have been racing to develop a vaccine, but there are significant risks to undertaking human trials, and the process is costly. If all goes well, experts estimate the earliest a vaccine could become available would be early 2018.

That’s little comfort to travelers whose flights are already booked to Puerto Rico, Mexico, or Brazil. Still, said Scully, it’s a matter of taking a calculated risk.

Unlike some healthcare providers and athletes, she was not concerned that the 2016 Summer Olympics proceeded in Rio de Janeiro despite the outbreak.

“They did the best they could to look at predictive models,” she said of the International Olympic Committee. “I certainly don’t think it was unreasonable to proceed with the games. The risk of transmission in travelers who tend to wear repellent and stay in air-conditioned hotels is much, much lower than in locals.” (In fact, to date, the WHO has not received any official notification of Zika cases associated with the Olympic Games.)

Similarly, Scully sees no reason for all Central Coast residents to cancel their travel plans to Central and South America, though she makes it clear that pregnant women should stay clear of any region with active Zika transmission. For others, she recommends consulting with a healthcare provider before travel, and stocking up on mosquito repellent.

Wagging a finger playfully, Scully delivered her favorite travel medicine admonition: “If you don’t get bitten, you won’t get sick.”

Of course, she acknowledged, in the case of Zika, there’s also the possibility of sexual transmission. Still, the vast majority of Zika infections result from mosquito bites, and there are a number of effective ways to avoid being bitten. In each of her examination rooms, Scully keeps a basket of these products. There are repellents containing DEET, Picardin, oil of lemon eucalyptus, and IR3535, as well as mosquito nets to cover sleeping areas, and Permethrin, a chemical that can be sprayed on clothing to deter the insects. These products should be used by anyone traveling to a region where Zika is endemic, as well as areas with active

SANSUM CLINIC TRAVEL AND TROPICAL MEDICINE CENTER WWW.SANSUMCLINIC.ORG/TRAVEL-HOME SAN LUIS OBISPO COUNTY PUBLIC HEALTH DEPARTMENT WWW.SLOCOUNTY.CA.GOV/HEALTH/PUBLICHEALTH/ZIKA.HTM SANTA BARBARA COUNTY PUBLIC HEALTH DEPARTMENT HTTP://COSB.COUNTYOFSB.ORG/ZIKA_VIRUS CENTERS FOR DISEASE CONTROL WWW.CDC.GOV/ZIKA WORLD HEALTH ORGANIZATION WWW.WHO.INT/EMERGENCIES/ZIKA-VIRUS

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CENTRAL COAST PHYSICIANS

Fall 2016

®

transmission of other mosquito-borne pathogens.

Even in Central and South America, some regions remain far safer than others, she pointed out. For example, travelers targeting Machu Picchu in Peru have little to worry about, since Aedes mosquitoes are generally not found at elevations higher than 6,500 feet.

For those who elect not to travel at this time, Scully noted, it’s still worth taking precautions here at home. The vector mosquito for Zika may not currently be with us on the Central Coast, but other disease-carrying mosquitos are, including those that transmit West Nile virus. Wearing long sleeves and pants, avoiding areas with standing water, and wearing repellent are measures worth taking to protect your own health and prevent the potential spread of disease. Health officials in San Luis Obispo and Santa Barbara counties also encourage residents to use screens and air conditioning when available, and to prevent mosquito larvae from breeding by emptying and cleaning any outdoor items that hold water – such as buckets and watering cans – on a weekly basis.

In the coming weeks and months, it’s likely the number of travel-related cases of Zika in San Luis Obispo and Santa Barbara counties will rise. Still, officials agree, there’s little risk of a Zika epidemic on the Central Coast; in the absence of the vector mosquito, it’s impossible for the virus to achieve sustained transmission.

Meanwhile, in hot spots like Brazil, there’s a good chance Zika’s status will shift over time from epidemic to endemic as the majority of local residents are infected with the virus and develop immunity. In that case, the risk to travelers would become much lower. Models published recently in the journal Science suggest that Zika will reach this point within three years.

Even if these predictions prove accurate, those without immunity will always be at some risk of infection. According to mosquito vector specialists like Chang, it’s highly unlikely we’ll ever succeed in eradicating Aedes aegypti and Aedes albopictus populations, which means travelers should continue to take the risk of Zika infection seriously and protect themselves from mosquito bites.

In that sense, at least, Zika is nothing new to Scully.

On the wall of her examining room hangs a colorful map of the world. It serves as an enticement to intrepid travelers as well as a handy visual reference for tracking infectious disease outbreaks. As she talks about Zika, Scully traces her finger along the map’s surface, hovering over Florida, Puerto Rico, Brazil, and Singapore. Beneath her fingers run many more invisible pathways – the routes taken by viral epidemics past and those yet to come.

For a moment, the faint buzz of the fluorescent light sounds almost like a mosquito.

Fall 2016

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Public Health

Update County Health Priorites: CHA Survey, N=2628 24, 1% 42, 2% 46, 2%

43, 2%

22, 1%

19, 1% 11, 0% 8, 0%

52, 2%

Regular Exercise

69, 3%

Housing 567, 22%

Obseity

76, 3%

Mental Healthcare Sufficient Food

78, 3%

Health Insurance Neighborhood Safety Substance Abuse Counseling

213, 8%

Family Planning Clean Living Diabetes 423, 16% 252, 10%

Quit Smoking ImmunizaTons

The The Santa Barbara County Public Health Department will be developing a Community Health Improvement Plan to identify priority issues, develop and implement strategies for action, and establish accountability to ensure measurable health improvement. If you have specific recommendations, please feel free to contact Susan Klein-Rothschild at sklein@ sbcphd.org.

Heart Disease Oral Health Cancer DemenTa

304, 12% 379, 14%

DomesTc Violence Support

To view the entire assessment, go to www.sbcphd.org.

Community Health Assessment for Santa Barbara County 2016

By Susan Klein-Rothschild, MSW • Deputy Director, Community Health • Santa Barbara County Public Health Department

The Santa Barbara County Public Health Department has completed a Community Health Assessment of our county residents. It provides a perspective on the community’s current health and priority areas for improvement. This assessment took a two-pronged approach: we completed a survey of county residents and we analyzed health related data. The findings are interesting and helpful for future planning.

COMMUNITY SURVEY The community survey was completed by over 3,000 adult residents (18 years and older). It was available in English and Spanish, electronic and hard copy versions, and outreach was made to reach underserved populations. This was not a random survey.

Three-quarters of the respondents were female and 46 percent identified as Hispanic or Latino.

When asked about the status of their health, over three-quarters of

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CENTRAL COAST PHYSICIANS

the respondents reported they were in good, very good, or excellent health. Yet body mass index (BMI) reports do not necessarily match self-reports of health status. Based on self-reports of height and weight, BMI was calculated and we found that 37 percent were in the healthy BMI range, 33 percent were in the overweight category, and 28 percent were in the obese category. We know from research that people often over-report height and under-report weight.

Fall 2016

The survey asked respondents to identify health priorities in three ways: for themselves as individuals, for their households, and for the entire county.

The responses were strikingly similar. In all categories, regular exercise, healthy eating/obesity, mental healthcare, and housing were listed in the top four.

These are statistically significant factors that contribute to the health of the whole person; including our physical, mental and social, and spiritual well-being.

CATEGORY

NATIONAL PREVALENCE PERCENTAGE

ESTIMATED NUMBER IN SBC

Serious mental illness – Adults

4%

13,584

Serious emotional disturbance – children

5% -8%

4,902 - 7,843

Adult substance use disorder

8%

27,169

Regarding individual health priorities, regular exercise was identified by 46 percent of the respondents. This is followed by health eating habits with 29 percent.

When responding for household health priorities, healthy eating was most frequently identified by 38 percent closely followed by regular exercise at 31 percent.

County Health priorities reflect more divergence in responses, yet the top priorities remain regular exercise, obesity/health eating, housing, and mental healthcare.

HEALTHY EATING AND PHYSICAL ACTIVITY Healthy eating and physical activity are the building blocks to healthy development and a lifetime of good health. A poor diet combined with physical inactivity can result in obesity. The single best predictor of type 2 diabetes is if an individual is overweight or obese. Data from the California Health Information Survey at UCLA reflects an increase in diabetes in Santa Barbara County.

Obesity is a major problem that contributes to many health problems but we have limited data on obesity in Santa Barbara County.

According to our Women, Infant and Children (WIC) program in the county, out of approximately 11,000 children between the ages of two and five, 13.9 percent were in the overweight category and 13.7 percent were in the obese category. With approximately 1,600 prenatal women, 29.1 percent were overweight and 29.2 percent were obese.

MENTAL HEALTHCARE Mental and emotional well-being is essential to overall health. There is a strong connection between mental health and physical health.

Poor health can lead to an increased risk of developing mental health problems. Similarly, poor mental health can negatively impact physical health and mask physical health conditions that can be treated, leading to an increased risk of some conditions. Mental and physical health are inextricably linked.

HOUSING Health and health problems are directly related to living in healthy and safe home environments. Safe housing includes access to clean air and water, efficient transportation, safe/walkable neighborhoods, affordable, health foods, violence-free places for recreation, and affordable secure quality housing. Three areas that reflect impacts of housing and health are affordability, stability, and quality.

DATA HIGHLIGHTS The assessment includes mortality and morbidity data from a number of sources and covering a variety of health related areas.

This information is independent of the community survey.

One area of concern is sexually transmitted diseases (chlamydia, gonorrhea, and syphilis) which have been rising significantly in Santa Barbara County. Syphilis is a good example. Although the number of cases is small, the increase is significant.

One area with positive trends is related to maternal child health.

Rates of low birthweight babies, rates of births to teenage mothers, and premature births are all decreasing. Breastfeeding rates are also high in our county.

The assessment provides extensive data in many areas not covered in this brief summary along with references and related information.

I urge you to go to www.sbcphd.org to view the entire report.

Information from the Community Health Assessment can be a powerful tool to educate our community, inform the development of strategic plan to improve health, inform decision makers, and track improvement of health care outcomes. The Public Health Department will be developing a Community Health Improvement Plan to identify priority issues, develop and implement strategies for action, and establish accountability to ensure measurable health improvement. If you have specific recommendations, please feel free to contact Susan Klein-Rothschild at sklein@sbcphd.org.

To view the entire assessment, go to www.sbcphd.org.

Definitive local data on the prevalence of serious mental illness and substance use disorder is not available. Based on the county population of 437,643, we can estimate the number of residents with serious mental illness and substance use disorders.

Fall 2016

CENTRAL COAST PHYSICIANS

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PHOTO: PHOTO CREDIT DAVID BAZEMORE

POLST Update

PHYSICIAN ORDERS FOR LIFE SUSTAINING TREATMENT

BY JEANNE M. WEST, RN, MHA • ENROLLMENT COORDINATOR • DOCTORS ASSISTING SENIORS AT HOME

Physician Orders for Life Sustaining Treatment (POLST) was introduced in California in 2008 with the passage of AB 3000. This form serves as a medical order that gives seriously ill patients more control over their care. The bright pink form must be signed by the both the patient and doctor and it specifies the types of medical treatment that a patient wishes to receive at the end of life. It is meant to speak for patients when they are unable to verbalize or otherwise indicate their care preferences. The main purpose of the form is to ensure that patients receive the treatment that they want and avoid treatment they don’t want, thereby reducing patient and family stress at a difficult time. Over the past seven years, it has gained in use and recognition in all health care settings and is now readily requested and recognized by first responders when 911 is summoned to a home or long term care facility.

While discussions regarding the form often are facilitated by nurses, social workers, and other health care providers, up until this time only the physician’s signature would validate and activate the form. As a result of new legislation (AB 637), which was passed into law in August of 2015, the California POLST forms are now able to be signed by nurse practitioners and physician assistants, as well as by physicians, giving the form legal validity. Co-sponsored by the

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CENTRAL COAST PHYSICIANS

California Medical Association and the Coalition for Compassionate Care of California, the new law went into effect on January 1, 2016.

Best practice is for nurse practitioners and physician assistants to only use the 2016 revised POLST form, and they are advised against signing old versions of the POLST, since those versions do not have provisions for their signatures, nor is there clarification that their signatures are now valid. All forms (2009, 2011, and 2014 versions) remain valid if properly completed and there is no need to complete a new 2016 POLST form, unless the patient’s care preferences have changed.

Despite this change, the form will continue to be called the “Physicians Orders for Life Sustaining Treatment” (POLST).

A space has been added to indicate the name of the supervising physician, which is in compliance with existing regulations; however, a supervising physician is not required to countersign the form.

A PDF of the 2016 POLST form is now available at www. caPOLST.org. The form can be downloaded and printed on ultrapink colored cardstock. Forms can also be purchased through the California Medical Association’s Resource Library at www.cmanet. org/resource-library.

Fall 2016

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YES on

56

California’s Proposition 56 Will Raise Tobacco Tax to Save Lives, Protect Children In November, Californians will have a vital opportunity to stand up to tobacco companies and save lives. Proposition 56 will raise the tax on cigarettes and other tobacco products, including electronic cigarettes containing nicotine, which medical experts warn are creating a major public health threat to children.

Prop. 56 directs additional funds to the University of California for graduate medical education, Denti-Cal, the California Department of Public Health and the California Department of Education for smoking prevention programs, and the University of California for medical research into tobacco-related diseases.

Taxing tobacco saves lives and gets people to quit smoking.

Taxing tobacco is proven to prevent would-be smokers – including youth – from ever starting. And only those who choose to continue or start this deadly and costly habit will pay.

Prop. 56 will protect children. Studies show that 90 percent of smokers start as teens. This year alone, an estimated 16,800 California youth will start smoking, one-third of whom will eventually die from tobacco-related diseases.

The California Medical Association has joined the American Cancer Society Cancer Action Network, American Lung Association in California and American Heart Association in sponsoring Prop. 56, because tobacco hurts all Californians – even those who don’t smoke.

Tobacco companies are aggressively marketing youth-themed, candy-flavored electronic cigarettes containing nicotine to hook a new generation of young consumers. Teen use of e-cigarettes tripled in a single year, and flavored tobacco products are creating a dangerous new public health threat, particularly to youth and minorities. Teens who use e-cigarettes are twice as likely to start smoking traditional cigarettes.

The leading cause of preventable death in our state and the nation, tobacco kills 40,000 Californians annually. Each year, tobacco causes more deaths than guns, car accidents, HIV, alcohol and illegal drugs combined. Meanwhile, Californians spend $3.5 billion dollars each year treating cancer and other tobacco-related diseases through Medi-Cal. Only those who use tobacco products will pay this simple user fee.

The vast majority of funds generated by Prop. 56 (estimated to be up to $1 billion annually with an additional $1 billion in federal matching funds) will go to pay for health care for low income Californians through Medi-Cal. Medi-Cal now serves over 12 million people, almost one third of the state’s population and half of all California children.

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CENTRAL COAST PHYSICIANS

It has been proven that higher tobacco taxes reduce teen smoking, yet California’s tobacco tax is among the lowest in the nation.

Prop. 56 will keep kids from becoming addicted to nicotine.

Prop. 56 will safeguard children and improve California’s communities, economy and health care system. Although we have made some great strides, we cannot stand down from combatting tobacco’s deadly addiction. Learn more at YesOn56.org.

Twitter: @YesOn56 Facebook: @YesOn56 Instagram: @YesOn56

Fall 2016

CALIFORNIA MEDICAL ASSOCIATION

PROTECTING YOUR PROFESSION standards and oversight puts the safety and health of patients at risk.

WHAT CMA DOES FOR OPHTHALMOLOGISTS Medicare Payment Reform: CMA was integral in the passage of federal legislation to reform the badly broken Medicare physician payment system. This legislation will stabilize the physician payment system and is worth hundreds of millions of dollars to physicians nationwide over the coming decade. CMA was also key to the passage of the long overdue “California GPCI fix,” which will The Recognized Voice ofpayments California Physicians update the Medicare localities and increase to physicians in many counties by more than $400 million in the next 10 years.

MICRA: and its county societies led the successful fight against the trial lawyers’ Proposition 46,physicians in one of the most CMA and CMA its county medical societies have represented California’s forconten160 tious and high-stakes ballot fights in California history. Had it passed, the ballot measure would have decimated the landmark Medical years the recognized voicewhich of the house medicine.

CMA alsofor partners with Injuryas Compensation Reform Act (MICRA), has kept access of to affordable health care a reality patients acrossregularly the state. CMA defends this landmarkof lawCalifornia, year after year. The of Californiawe ultimately rejected Prop. our 46 by combined one of the widestvoices margins in thestalwartly specialty societies andvoters together stand taller, state history (67 percent to 33 percent). stronger, fighting for the future of medicine and our noble profession.

Taking on Big Tobacco: CMA helped launch the new “Save Lives California” coalition, committed to raising the state’s tax

Working tocoalition Protect Your Specialty on tobacco. The is working to strengthen the state’s anti-tobacco policies to prevent death from tobacco-related diseases and reduce the costs of smoking on California’s health system. In 2016, we successfully passed a sweeping series of tobacco control

Over the past several years, optomotrists have launched an unprecedented number of bills—including raising the legal age to purchase tobacco from 18 to 21—an action that will undoubtedly save countless California children attacks to expand their scope of practice. CMA and our specialty society partners have from a deadly, lifetime addiction to nicotine. vigilently defended these and other attempts to irresponsibly expand the scope of practice Physician practitioners.

Workforce:CMA We are committed to expanding funding for GME to ensure that there are enough residency slots to train of non-physician strongly believes that allowing practitioners to perform physicians in regions where health services are needed most.and CMA to secure procedures they aren’t trained to do care can threaten patient safety leadwas to able higher costs $100 million in the 2016-2017 state budget to expand the Song-Brown Program to create more residency slots in California. and greater fragmentation of care.

Key Victories and Priorities

There are 821 ophthalmologist members of CMA.

Scope of Practice: Every year, CMA dedicates a vast amount of resources to the successful defeat of several scope-of-practice expansion attempts before the State Legislature. Each of the bills claims to be a solution to California’s access to care crisis, but, in reality, they each posed a very real danger to patients.

WON’T YOU JOIN US?

SB 492 (2013 and 2014) and SB 622 (2015) would have both allowed optomotrists to an array of supplementary procedures with little additional training, including scalpel surgeries, laser surgeries and WE intraocular injections.

Through diligent lobbying and with the ARE HERE FOR YOU engagement of our physician members calling and writing to their • CMA and its county medical societies – representing 41,000 physicians, residents and medical students – influence public policy at legislators, CMA convinced lawmakers that lowering certification the state and federal levels.

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Members have free access to valuable professional resources, including nearly 5,000 pages of legal information related to the practice of medicine in CMA’s online health law library.

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Our extensive network of benefit partners makes it so that your membership can easily pay for itself.

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As an ophthalmologist, I’m proud to be a CMA member because CMA advocates CMA only apatients’ phone call away!

Our live-person centerbest is available Mon-Frimedical during business at (800) 786-4262. foris my rights to havecall the quality andhours surgical care.”

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Join today to activate your personal webDouglas account at www.cmanet.org.

Jacobson, M.D., Ophthalmologist, Member Since 2012

FOR MORE ABOUT CMA AND ITS PROGRAMS, VISIT WWW.CMANET.ORG. Rev. 07/11/16

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OR 404 ERROR 404 ERROR 404 ERROR 404 ERROR 404 ERROR 4

BY ROBERT W WONG, MD ORIGINALLY PUBLISHED AT WWW.36THANDHAMILTON.COM ON SEPTEMBER 13, 2016.

LAST SUMMER, OUR PRIVATE PRACTICE OF EIGHT RETINAL SPECIALISTS DECIDED TO FIND OUT EXACTLY HOW COMFORTABLE. From July to August 2015, we conducted a survey of 200 of our patients during their office visit and asked them what health-care related tasks they were already doing online. Using this data, we’re starting to look at how our medical practice might evolve to better serve our patients.

Specifically, we wanted to know how many of them used their smartphone, tablet, or personal computer to perform these routine health related tasks: 1. Schedule a doctor’s appointment

2. Pay a medical bill

3. Read an online doctor review

4. Research a medical condition In general, utilization of online service to do any of these was inversely proportional to age.

OR 404 ERROR 404 ERROR 404 ERROR 404 ERROR 404 ERROR 4 34

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Fall 2016

404 ERROR 404 ERROR 404 ERROR 404 ERROR 404 ERROR 40

Scheduling a Doctor’s Appointment

Even though our practice is largely referral-based (meaning other doctors send patients to us to help diagnose and manage their condition), we are seeing that many of our younger patients prefer the convenience of scheduling an appointment online much like they would use OpenTable.com to make a dinner reservation. Online outfits like ZocDoc seem to thrive on this type of service.

Paying a Medical Bill Online

Who has stamps anymore? Online commerce is everywhere and people are more comfortable than ever with online payment platforms. 21st century medical practices should consider creating an online portal on their websites able to take payments.

Not only is this more convenient, anytime you can make it easier for patients to settle their medical bill can only help your bottom line. The next question is whether or not your practice is going to accept Apple or Samsung pay.

Read Online Doctor Reviews

Yup. Our patients read them and doctors can’t ignore them, no matter how good you think you are.

It’s well known that consumers are more likely to post a scathing review reporting terrible service than to post one of great care that they have come to expect as standard.

It doesn’t matter if most of your patients are medicare-aged where only 27% of them actually read your reviews. Why? Because younger people consider them important and younger people often help their parents choose a doctor.

Likewise, younger patients will eventually become your older ones.

Do yourself a favor, look up your reviews. If there are any One Star duds, bury them with a ton of Five Star complements.

Consider services like reputation.com to help you follow and ultimately boost your ratings. In a digital world where we are constantly measured in “LIKES,” you’ve got to play the game.

Research a Medical Condition

Our findings show that a large majority of patients, young and old, are scouring internet media to see if a “sudden onset of

cobwebs” in their vision is normal. Because of this, it makes sense to update your practice’s website with the most up-to-date medical information within your specialty. Stay current. Put it in layman’s language.

Consider providing links to reputable online sources such as your professional academy’s website or well respected medical institutions like the Mayo Clinic or CDC.gov.

Also, during visits, be prepared for a much more “informed” patient and be open to guiding them towards useful online resources. An “informed” patient is much better than a misinformed one and you can’t always believe what you read on the internet. Blogs included!

Stay Ahead of the Competition

Healthcare will always be a service profession. Part of providing great service is being able to adapt to how our patients continue to change how they manage their health.

Perhaps our research may help practices decide whether or not to offer specific online services. Each medical practice should decide for themselves if it’s worth the investment based on their patient population’s preferences.

I wouldn’t be surprised that in the near future, practice websites might include patient portals, virtual avatars, and telemedicine at a click of button.

Just remember, all the bells and whistles on your website won’t ever replace sound medical decision making and great bedside manner in the overall care of your patient.

But, it might help them find you.

404 ERROR 404 ERROR 404 ERROR 404 ERROR 404 ERROR 40 Fall 2016

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MACRA

RESOURCE CENTER Tools and information to help physicians understand the Medicare payment reforms

Learn more at www.cmanet.org/macra Wondering where to start? There are some critical first steps that physicians should take to prepare for MACRA implementation. The most important step is to get educated about MACRA. Some specific actions to consider include: Learn the basics of MACRA – Under the MACRA proposed rule, there will be two main pathways for physician reimbursement, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). For an overview on the two pathways, download AMA’s MACRA Action Kit (see page 5), which also includes a checklist (see page 2). Also, watch the California Medical Association (CMA) webinar titled, “What Is MACRA? What Is CMA Doing to Improve It? What Steps Can You Take to Prepare Now?” and the Centers for Medicare & Medicaid Services (CMS) webinar, “MACRA and the Quality Payment Program: An Update on the Recent Proposed Rule.” The webinars will allow you to view at your own pace and will give you the basics of MACRA. Remember that this is a proposed rule and is not final – CMS issued its proposed rule on April 27, 2016, and received many comments from interested stakeholders, including CMA. The final rule is expected this fall. CMA encourages practices to get ready, but to remember that the details are subject to change. To read CMA’s comprehensive comments to CMS outlining constructive improvements to MACRA, visit www.cmanet. org/macra. There you will also find a link to AMA’s extensive comments.

Determine whether you are exempt from MIPS participation – The proposed rule exempts practices from MIPS if they have a low volume of Medicare patients. This threshold is defined as $10,000 or less in Medicare billed charges and 100 or fewer Medicare patients

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annually. Physicians in their first year of Medicare participation are also exempt.

Determine whether your practice meets the requirements for small, HPSA, or non-patient facing physician accommodations and exceptions – The proposed rule provides accommodations and additional flexibility for various practice sizes and configurations. See the CMS Small Practices Fact Sheet for more information.

Participate in PQRS for 2016 – Whether your practice ends up participating in MIPS or APMs, there will be a quality reporting component. If you haven’t yet successfully participated in CMS’s Physician Quality Reporting System (PQRS), try again in 2016. CMS has created a 2016 PQRS Implementation Guide that includes a beginner reporter toolkit to help get you started.

You’ll gain familiarity with the reporting process and will have access to view your PQRS feedback reports, which can help to guide practice improvements under MACRA. Review QRUR reports to identify where improvements can be made – CMS publishes a mid-year and annual Quality and Resource Use Report (QRUR) to help practices understand their cost and quality assessments under the Value Modifier and quality under PQRS. To access your practice’s QRUR report, visit the CMS Enterprise Portal. One person from the practice will need to obtain an Enterprise Identity Management System (EIDM)

Fall 2016

MACRA > Medicare Reform

account. For more information on setting up an EIDM account, visit the CMS website.

Review proposed measures and determine how you will report – Decide which measures will work for your practice and how you will report the data to CMS. For more information on the proposed individual quality measures for MIPS, see Tables A – G on pages 28,399 – 28,569 of the proposed rule.

Under MIPS there are four reporting categories that allow for different reporting mechanisms: through claims, electronic health records, clinical registry, qualified clinical data registry or the group practice (25+ physicians) reporting option web interface. For more information on reporting mechanisms, see CMS’s “The Merit-Based Incentive Payment System (MIPS)” slide deck (begins on slide 43).

Consider participating in a qualified clinical data registry – If you are not already participating in a qualified clinical data registry, contact your specialty society about participating in theirs. Data registries are a method of reporting that can assist reporting in three of the four MIPS categories.

Evaluate EHR and vendor readiness – Is your EHR considered certified EHR technology (CEHRT)?

– Make sure your EHR is certified. To see which EHR systems are CEHRT, see the CMS website.

Talk with your EHR vendor about how its product supports transition to MIPS – Find out whether your vendor will meet Medicare MIPS quality reporting requirements or new payment model adoption. Are there any costs associated with needed updates? Ask about timelines for MACRA readiness and interoperability. Document the conversations.

Review CMS’s list of CPIA – Determine which clinical practice improvement activities (CPIA) your practice is already doing and what adjustments need to be made to complete additional activities by 2017. For a list of high weight CPIA categories, see Table 23 on pages 28,263 28,265 of the proposed rule. For a complete list of proposed CPIA, see Table H on pages 28,570 - 28,586 of the proposed rule.

Consider ways your practice can report at least one unique patient for each Advancing Care Information (ACI) measure – ACI will replace the EHR incentive program. Practices should ensure they can report at least one unique patient (or answer “yes”) for each measure of the base score’s six objectives. Ideas (for 2017) include: •

Reach out to existing patients to encourage use of the patient portal.

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If your EHR allows you to send a secured message through your patient portal to all of your patients at once, you might consider sending an appointment reminder to all of your patients in 2017.

Fall 2016

•

For a complete list of the proposed ACI categories, see Table 6 on pages 28,222 – 28,226 of the proposed rule (with additional information in Section II.E.5.g.7).

Conduct a security risk analysis in early 2017 – Failure to do so will result in a score of zero for the ACI category. The risk analysis should comply with the HIPAA Security Rule requirements. For more information on conducting a HIPAA security risk analysis CMA members have free access to our on-demand webinar, “HIPAA Security Risk Analysis: How to Make Sense of this Requirement” available on our website at www.cmanet.org/webinars.

Additional information can be found in CMA On-Call Document #4102, “HIPAA Security Rule,” also free to CMA members in the online health law library at www.cmanet.org/cma-on-call. The American Medical Association (AMA) website also has resources to help with this step at www.ama-assn.org/go/hipaa.

View AMA’s STEPS Forward Practice Transformation Series learning module – To help practices make the shift to value-based care, AMA has created the STEPS Forward learning module. The module includes five steps to prepare a practice for value-based health care, answers to common questions and case vignettes describing how physicians can create value-based practices.

Confirm whether you are a participant in any of the advanced APMs already approved by CMS – For a list of the CMS-approved advanced APMs in the proposed rule, see Table 32 on page 28,312.

Stay up-to-date on MACRA related news.

•

Sign up to receive CMS MACRA e-mail updates.

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Sign up to receive Medicare news directly from CMA through content update alerts. By doing so, you will be notified anytime a new story about MACRA is posted to our website.

To do so, just activate your web account (if you haven’t already done so) and sign up for custom content alerts on the topics that are of interest to you. You will then be notified any time there is new content posted in one of your interest areas. To do so, 1) Click on “My Account,” 2) In the left sidebar, click on “My Alerts,” 3) Under New Content Alerts, click “Alert Settings,” 4) Type “Medicare” in the search box and hit enter.

You can adjust the frequency and format that you receive alerts via the account dashboard. For more information, see www.cmanet.org/custom-content.

Check CMA’s MACRA Resource Center at www.cmanet.org/macra for updates!

For additional information on steps you can take now to prepare, see the AMA MACRA checklist (pages 2-3).

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12 NEW

THE CENTRAL COAST MEDICAL ASSOCIATION WELCOMES THE FOLLOWING PHYSICIANS AS MEMBERS

...and even more on the way.

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Benton Ashlock, MD Pulmonary Critical Care Medicine Sansum Clinic Santa Barbara 805.898.3400 www.sansumclinic.org

Joseph Freemen, MD Emergency Medicine Santa Barbara 805.682.7111 South Coast Emergency Medical Group

Sharon M Kim, MD Family Practice Sansum Clinic Lompoc 805.737.8700 www.sansumclinic.org

Kevin Casey, MD Vascular Surgery West Coast Vascular Santa Barbara 805.643.3330 www.westcoastvascular.com

Robert W Fry, MD Orthopedic Surgery Sansum Clinic Lompoc 805.737.8700 www.sansumclinic.org

Jennifer Kosek, MD Diagnostic Radiology Pueblo Radiology Medical Group 805.682.7984 www.puebloradiology.com

Carol Del Ciello, MD Anesthesiology Santa Barbara 805.452.6224

Sharon Goldberg, MD Obstetrics and Gynecology Santa Barbara 805.452.0703

Philip Ente, MD Neurology Lompoc 805.735.7623

Taylor J Holve, MD Cardiovascular Disease Sansum Clinic Santa Barbara 805.681.7500 www.sansumclinic.org

CENTRAL COAST PHYSICIANS

Lawrence Li, MD Family Practice Sansum Clinic Lompoc 805.737.8700 www.sansumclinic.org Caleb Thompson, MD Interventional Cardiology Santa Barbara Cardiovascular Medical Group Santa Barbara 805.682.7707 www.sbcardio.com

Fall 2016

In Memoriam

Cameron Lindberg, MD • Charles E Piper, Jr., MD Cameron Lindberg, MD November 1, 1992 – June 6, 2016

Charles E Piper, Jr., MD December 2, 1927 – October 4, 2016

Doctor Cameron “Cam” Eugene Lindberg was born November 1, 1942. Second-generation SwedishAmerican, his parents were Gustav and Edna Lindberg in Kansas City, Missouri. He attended the UCLA School of Medicine and received his Doctorate of Medicine degree in 1971. In 1976, he completed his residency in orthopedic surgery through UC Irvine.

While completing his residency at Long Beach Veterans Hospital, he met the love of his life, Charlene Fry, who ran the residency office desk. They moved to the South Lake Tahoe/ Carson City area together to open his first practice in 1976.

In 1981, the family moved to Lompoc, California, where he opened his second practice, Lompoc Orthopedic.

Dedicated to his practice and devoted to his patients, Dr. Lindberg was still fully in practice when he passed, and Lompoc Orthopedic was in business for 35 years. He lived to work and contribute to the medical community; he participated in bringing the first MRI machine to Lompoc.

Convicted and unrelenting in the war against type 2 diabetes, he dedicated his life’s research to trying to find cures for the disease.

Cameron Lindberg is survived by his loving wife Charlene Lindberg, brother Keith Lindberg, sister Gale Lindberg, his three children Lisa Lindberg, Bradley Lindberg and Cassandra Lindberg, along with his grandchild, Soren Lindberg.

Dr. Lindberg was a member of the Central Coast Medical Association for 29 years.

Doctor Charles “Charlie” Piper was born in Pittsburgh, Pennsylvania, on December 2, 1927. He attended University of Pittsburgh Medical School from 1948-1952 followed by an internship at Allegheny General Hospital. He was admitted to surgical residency at the Mayo Clinic in 1953 through 1956 and also completed a preceptorship at Louisville Children’s Hospital.

Dr. Piper served as a medical officer in the Navy on the USS Burton Island during the Korean War and at San Diego Naval Hospital. Having experienced the fine weather of Southern California, he said goodbye to Pennsylvania and came to practice general surgery in Santa Barbara with Drs. Ken Jennings and John Rydell at Pueblo Surgical Center.

During his long surgical career, he also practiced with Drs. George Wittenstein, Hewitt Lang, and David Kolegraff. He was a fellow in the American College of Surgeons and the Priestley Society. Dr. Piper served several terms on the Hope School Board of Trustees and was a doctor on the Ranchero Vistadores Ride.

In his retirement years, he enjoyed vegetable gardening, ocean fishing, Bonsai, and walking his dog “Oso” who really misses him.

He is survived by Judy, his wife of 53 years, his two daughters Cynthia Heise (Brant) of Palos Verdes Susan Nielsen (Erik) of Santa Barbara, and four grandchildren: Keaton, Trevor, Piper and Carley.

Dr. Piper was a member of the Central Coast Medical Association for 56 years.

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