December 2017

DECEMBER 2017 OFFICIAL PUBLICATION OF SDCMS

CANNABIS HYPEREMESIS SYNDROME: ‘SCROMITING’ San Diego County Medical Society Makes International News Identifying New Condition

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DECEMBER

CONTENTS

VOLUME 104, NUMBER 12 EDITOR: James Santiago Grisolía, MD EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: Mark W. Sornson, MD, PhD President-elect: David E.J. Bazzo, MD Secretary: James H. Schultz Jr., MD Treasurer: Holly B. Yang, MD Immediate Past President: Mihir Y. Parikh, MD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Sergio R. Flores, MD (Board Representative to Executive Committee) Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Geva E. Mannor, MD, MPH La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Michael A. Lobatz, MD South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD

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GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County: Neelima V. Chu, MD South Bay: Paul Manos, DO

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5 feature

San Diego Immunization Registry

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Cannabis Hyperemesis Syndrome

Physicians Can be at Risk when Homebound Patients Refuse Help

BY SDCMS’S RONEET LEV, MD, FACEP

departments 4 Briefly Noted: Calendar • Promote Flu Vaccinations • Weekly Podcast • Volunteer Opportunities • And More ...

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BY ROBIN DIAMOND, MSN, JD, RN

18 Flu Vaccinations Mandated for Healthcare Personnel

BY SAN DIEGO COUNTY HEALTH AND HUMAN SERVICES AGENCY, PUBLIC HEALTH SERVICES

Emergency Care by the Bay

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BY RONEET LEV, MD, FACEP

The Quality Payment Program: What You Need to Know for 2018

8 The Best Time to Plant a Tree

BY HELANE FRONEK, MD, FACP, FACPh

10 Deadly Hepatitis A Virus Outbreak, San Diego County

BY ROBERT E. PETERS, MD, PHD

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AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Karrar H. Ali, DO, MPH; #3: Alexexandra E. Page, MD; #4: Nicholas J. Yphantides, MD; #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Erin L. Whitaker, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD ADDITIONAL VOTING DIRECTORS Communications Chair: J. Steven Poceta, MD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Meghana Pagadala ADDITIONAL NON-VOTING MEMBERS Alternate Young Physician Director: Heidi M. Meyer, MD Alternate Resident Physician Director: Zachary T. Berman, MD Alternate Retired Physician Director: Mitsuo Tomita, MD\ San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MP

AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Lisa Miller, MD At-large AMA Delegate: Albert Ray, MD (appointed by CMA) At-large AMA Delegate: Robert E. Hertzka, MD (appointed by CMA) At-large AMA Alternate Delegate: Theodore M. Mazer, MD (appointed by CMA)

BY BETH HICKERSON

26 Physician Marketplace Classifieds

28 California Medical Association 2017 Year In Review

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted.

Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org.

All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// CALENDAR JAN 9-10: The California Department of Public Health (CDPH) Prescription Drug Overdose Prevention (PDOP) Initiative has partnered with the Harm Reduction Coalition to offer a free, two-part webinar series around naloxone. For more information, go to the events page at www. sdcms.org.

JAN 20: CME Offered by the San Diego Psychiatry Society. Technology in Psychiatry: Navigating Social Media, EHR and Telepsychiatry. Saturday, Jan. 20, 8:30 a.m.; Sharp Tech Center, 8520 Tech Way, San Diego, CA92123. Special $10 registration for SDCMS members. To register, go to www.sandiegopsychiatricsociety.tix.com.

MARCH 1-2: Future of Genomic Medicine at Scripps Institution of Oceanography, La Jolla After attending this activity, participants should be able to: Demonstrate the unmet needs of medicine today with respect to more targeted, individualized prevention and treatments; discuss the opportunities of the genome, proteome, and metabolome discovery to change medical practice as it exists today; assess how changes and advances in technology are rapidly ushering in a whole array of new pathways for individualized medicine of the future; and explore specific strategies in cancer, idiopathic and pharmacogenomic disease interventions. For more information and to register, go to https://www.stsiweb.org/event/fogm18.

GIVING BACK

VOLUNTEER OPPORTUNITIES Email Your Volunteer Opportunity Ads to Editor@SDCMS.org PHYSICIANS: HELP US IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care.

For further details on how you can get involved, please email Andrew.

Gonzalez@ChampionsFH.org.

CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal to receive short-term specialty care. Commitment can vary by practice. The mission of the

Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.

Gonzalez@ChampionsFH.org, or visit www.ChampionsforHealth.org. [282] SHORT-TERM MEDICAL VOLUNTEERS NEEDED FOR HAITI: We are looking for physicians, mid-level providers and nurses for one-week, primary-care medical clinics in rural Haiti in February, June, and October 2018. This is a rewarding and fun opportunity to work with the people of Haiti and provide care in a rural clinic in a medically underserved area. Seattle-King County Disaster Team (a U.S.-based nonprofit) has been operating these clinics since 1998. We coordinate all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or at labboy@earthlink. net if you are interested in applying.

Visit www.skcdteam.org for further information.

SDCMS Social Events 2018

Mark your calendars for next year!

Feb 22 (Thurs) Physician Networking Mixer April 26 (Thurs) Vendor Fair July 14 (Sat) Family Pool Party Oct 25 (Thurs) Physician Networking Mixer *dates subject to change.

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VACCINATIONS

Promote Flu Vaccinations In December, the Centers for Medicare & Medicaid Services invite you to help them on social media to promote flu vaccinations using the hashtags #FightFlu and #CalMediConnect! Share the message that getting an annual flu vaccination is important for beneficiaries and their families, care providers, and community members. Amplify your organization’s commitment to combating the flu this season by tweeting, blogging, and sending newsletters to your stakeholders.

QUOTE OF THE MONTH

Your success and happiness lies in you. Resolve to keep happy, and your joy and you shall form an invincible host against difficulties.

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DECEMBER 2017

”

— Helen Keller

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TrusT A Common sense ApproACh To InformATIon TeChnology

CMA INITIATIVE

CMA Launches Initiative Aimed at Firearm Violence “CMA recognizes that fundamentally, firearm violence is a human and civil rights matter; it violates the fundamental human right to life, liberty, and security of person—the right to live safely without fear in a free society,” the committee wrote in the position statement. “As with other public health issues, physicians have a unique responsibility as trusted public health figures to respond to the harms associated with firearm violence, both as individual clinicians and as community advocates.”

Through the committee’s work, CMA has identified several opportunities and resources that may aid physicians in addressing firearm violence as a public health issue. Learn more about what you can do to help prevent firearm violence at www. cmanet.org/firearm-violence.

PODCASTS

Listen to the Weekly ‘What the Health’ Podcast Each week, Julie Rovner, chief Washington correspondent for Kaiser Health News, along with top health policy reporters from The New York Times, The Washington Post, Politico and other media outlets discuss the latest news and explain what the health is going on here in Washington, DC.

MACRA

97% of physicians to avoid penalty under 2018 MACRA rule, according to CMS projections The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that will make changes in the second year of the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Though not perfect, the California Medical Association (CMA) is pleased that CMS has listened to physician feedback and made changes that will significantly reduce their administrative burdens, including providing additional accommodations for small and rural practices, allowing virtual groups, and providing bonus points for physicians who treat complex patients, such as dual eligibles, who now constitute nearly 40% of California’s Medicare population.

CMS now estimates that 97% of eligible physicians will avoid a penalty in 2020 for the 2018 reporting year, and that 73% of physicians will be completely exempt from MACRA’s Merit-Based Incentive Payment System (MIPS).

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C O N T I N U I N G E D U C AT I O N

EMERGENCY CARE BY THE BAY

by Roneet Lev, MD, FACEP

“THEY KEPT BRINGING out more and more chairs — that’s how I knew the conference was a hit,” said Dr. Leslie Mukau, director at El Centro Medical Center and moderator of the ED director panel.

The conference, Emergency Care By the Bay, was historic in that it was a partnership between the San Diego County Medical Society, California Emergency Nurses Association (Cal ENA), and The Doctor’s Company (TDC). “This may be the first of its kind of conference,” said Susan Smith, Cal ENA member and one of the conference organizers. Did doctors and nurses mind being together at a conference? “Not an issue,” said Dr. Jordan Cohen, director of Alvarado’s emergency department. “We are use to working in teams together.”

The location showed off the lovely San Diego bay front from the Kona Kai Resort hotel. The agenda was packed and fast paced, similar to a shift in the emergency department. It opened up with the state of the emergency department by Dr. Roneet Lev; the state of nursing by David Samuelson, RN, president of California ENA; and a vision to create the future of emergency medicine by BJ Bartleson, VP of nursing and clinical services, California Hospital Association.

The biggest problem with the conference was the triage decisions. Burn management or the ED director panel? Care of the transgender patient or Infectious disease?

Pediatric updates or responding to critical assaults? Marijuana madness or hot topics in EMS, DEA, tele-psychiatry, ambulance transfer of care, and nationwide case management sharing?

San Diego emergency medicine residents from the three programs at Kaiser, UC San Diego, and Naval Medical Center were given a complimentary invitation and a

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DECEMBER 2017

Scenes from the conference; Dr. Roneet Lev and Dr. Kobi Peleg. Photographs by Janice Ogar.

Our Doctor Loan could help eligible medical professionals buy a home¹ special lunch lesson by the father of emergency medicine, Dr. Peter Rosen.

Emergency providers are always interested in disasters. In the past the conference invited speakers from the Boston Marathon, Orlando Pulse club shooting, and Missouri tornado. This year we learned from Dr. Pablo Tovar, medical director at Ben Taub Emergency Department in Houston and what is was like for staff to live in the emergency department for a week. For the final speaker, instead of people skipping out early, we again had to bring in more chairs.

Professor Kobi Peleg, trauma director for the state of Israel and a world renowned disaster expert, gave a presentation that pushed our traditional thoughts of disaster preparedness with his experience with terror in Israel and disasters around the world.

Dr. Eric McDonald, public health medical director of epidemiology and immunization services at the County of San Diego, said, “We are so fortunate to have such leadership in our medical community, creating critical bridges between public health and emergency medicine, nurses and doctors, medicine and law enforcement, and multiple stakeholders across various specialties in attacking real problems. Well done!”

Dr. Lev, a 24-year member of SDCMS-CMA, is chief of Scripps Mercy Emergency Department, chair of the Prescription Drug Abuse Medical Task Force, and president of the Independent Emergency Physicians Consortium.

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P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T

THE BEST TIME TO PLANT A TREE

by Helane Fronek, MD, FACP, FACPh

YEARS AGO, on returning from my brotherin-law’s funeral, I discovered a colleague had been hospitalized with DVT. Tired at the end of a long day of seeing patients, I wanted to go home and spend time with my kids, thinking I could see my colleague the next day. Then it struck me that my 48-year-old brother-in-law had died suddenly while awaiting a heart transplant.

Instead of going home, I went to my colleague’s hospital room and we had a lovely visit. I had always regretted never telling him how instrumental he was in the course of my career. Without his encouragement, I would not have had the faith to enter a

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new field of medicine, where I discovered renewed passion and purpose. Recalling a beautiful Chinese proverb, “The best time to plant a tree is 20 years ago — but the second best time to plant a tree is today,” I shared my appreciation for the interest he took in me so many years earlier and let him know how profoundly he had impacted my career and my life. He died of an MI that night.

If I had gone home instead, neither my life nor his would have changed. Yet, to this day, I am grateful I made the effort and had a chance to thank him, even belatedly.

We all want to know that we matter, and I

wanted him to understand that, in addition to his many accomplishments in life, he mattered to me.

Showing gratitude after the fact is one thing, but there are many other times we discourage ourselves from planting trees because it’s no longer 20 years ago. How often do we turn away from new (or old, unexplored) interests because we feel we’re too old to start something new? How many times do we hear ourselves say, “I’ve always wanted to … ” and then invoke excuses for why we cannot try. What would our lives be like if, instead of saying no, we said yes to at least one new thing a day, a month, or even a year? How much more joy might we feel, excitement might we experience, or inspiration might we become for others if we planted those trees in our lives?

As we enter the holiday season, with its hectic array of activities, it’s natural to feel overwhelmed and believe we have no extra time. Yet, at these times, it becomes even more crucial to connect with ourselves.

One way to do that is to take a moment and consider one tree we would like to plant.

Is there something you’ve wanted to tell someone? A hobby you’d like to take up?

A book you’ve wanted to read? A mindfulness practice you’ve been yearning to start? Let’s commit to the first small step that will allow us to plant that tree so that, as we turn the page to 2018, we have a new and exciting accomplishment or prospect to build our confidence and excitement for the year to come.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com

SAN DIEGO PHYSICIAN.ORG

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H E PAT I T I S A U P DAT E

DEADLY HEPATITIS A VIRUS OUTBREAK, SAN DIEGO COUNTY Strategies for Containment and Prevention of Disease

By Robert E. Peters, MD, PhD

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ON SEPTEMBER 1, the San Diego County Public Health Officer declared a local public health emergency due to the ongoing hepatitis A virus (HAV) outbreak in the county.

San Diego and Santa Cruz Counties are currently experiencing outbreaks of hepatitis A infection. Public health officials have also identified cases due to the same HAV strain in other California counties, as well as in Arizona, Kentucky, and Utah.

As of November 20, 561 confirmed or probable HAV cases have been reported in an ongoing local outbreak in San Diego County. The cases had symptom onsets between November 22, 2016 and November 8, 2017. Three hundred and seventy-eight (67%) of the cases have been hospitalized, and 20 patients (4%) have died. The cases range in age from 5 to 87 years (median =

used the same homeless services providers and in the following types of facilities with shared restrooms: jails, single room occupancy hotels, residential drug treatment facilities, group homes, and assisted living facilities. Seven healthcare workers contracted HAV infection in this outbreak, as have 21 food handlers, although only two secondary cases have resulted from the individuals working in these sensitive occupations.

Vaccination and good soap and water hand hygiene are the two best preventive strategies against HAV.

44 years), and 382 (68%) are male, with 10 (3% of the male cases) self-identifying as men who have sex with men. The only pediatric case is an unimmunized 5-year-old who was exposed by an ill family member.

One hundred and seventy-nine (32%) of the HAV cases are homeless and reported injection or non-injection illicit drug use, 91 (16%) were homeless only, 67 (12%) were illicit drug users only, 162 (29%) were neither homeless nor drug users, and 62 (11%) had an unknown status for homelessness and drug use. Of the 452 cases with test results available for review, 78 (17%) have chronic hepatitis C infection, and 23 (5%) have chronic hepatitis B infection.

Most outbreak cases have been from downtown San Diego and from El Cajon, Santee, La Mesa, and the surrounding unincorporated areas. However, cases have been confirmed in all parts of the county.

The disease is being spread person to person, and, so far, no specific common food, beverage, or drug sources have contributed to the outbreak. Case clusters have been reported in individuals who have

Vaccination Public health departments face difficulties in providing access to vaccination efforts to the homeless and illicit drug use populations; such persons often receive only episodic healthcare in emergency departments. Offering vaccination in this setting is crucial to improving the vaccination opportunities of at-risk persons. Other places that vaccine should be offered are at homeless service providers, at outpatient medical, behavioral, and substance abuse providers, and at jails.

Those who work with at-risk populations should be vaccinated, including homeless services volunteers, sanitation and janitorial workers, public safety personnel, and healthcare providers. The County Public Health Officer strongly recommends HAV vaccination for all food handlers in San Diego County to reduce the potential risk of an ill food handler transmitting HAV to others.

The Advisory Committee on Immunization Practices routinely recommends HAV vaccination for various at-risk groups and “for any person wishing to obtain immunity.” Get two shots of the HAV vaccine spaced six months apart. The first dose of singleantigen HAV vaccine (Havrix®, Vaqta®) appears to protect more persons than the first dose of the combined HAV/HBV (Twinrix®) vaccine, but efficacy is comparable after completion of the respective series.

Under the Affordable Care Act, HAV vaccines are covered as preventive care without a deductible or copay. Adult HAV vaccination is covered by Medi-Cal without prior authorization.

Providers who do nothave available vaccine may direct patients to call 2-1-1 San Diego to locate the nearest County public health center, clinic, or pharmacy that can

provide the vaccine.

Suspect cases should be reported to the County Epidemiology Program while the individual is still at treatment facility in order to identify contacts and limit the spread of infection. The County will provide accommodations for those who are homeless and still infectious with HAV so that other homeless individuals are not exposed.

Hygiene Spread of fecally contaminated hands may play a significant role in the direct and indirect spread of HAV. As part of its Hepatitis A infection prevention efforts, the County has produced hygiene kits. These kits are being provided to community partners that serve vulnerable populations, such as homeless persons and illicit drug users. In addition, recent measures implemented in San Diego County include handwashing stations and street-cleaning initiatives.

Disinfection is important in preventing spread of virus. Healthcare workers should use contact precautions, in addition to standard precautions in patient care to protect themselves. HAV, like norovirus, is a non-enveloped virus, and it may be similarly difficult to inactivate in the environment. Alcohol-based hand rubs and typical surface disinfectants may not be effective.

Therefore, additional precautions to take include washing hands with soap and running water for at least 20 seconds after providing care for an HAV patient. Perform environmental cleaning in areas housing HAV patients with bleach products or products effective against norovirus.

Remember that vaccination and proper hygiene are the best prevention against hepatitis A infection. For updated details about the outbreak, sign up for health alerts by going to www.CAHANSanDiego. org or visit the County Epidemiology Program webpage at www.sdepi.org.

Special thanks to Dr. Eric McDonald, Medical Director of the Health and Human Services Agency’s Epidemiology and Immunization Services Branch, for providing critical information and statistics used in this article.

Dr. Peters, a 20-year member of SDCMS-CMA, is board certified in family medicine, a member of the SDCMS GERM Commission, past president of SDCMS and past chair of CMA’s Council on Ethical Affairs.

SAN DIEGO PHYSICIAN.ORG

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I M M U N I Z AT I O N

SAN DIEGO IMMUNIZATION REGISTRY The Secure, Web-Based Way to Access Immunization Information

DO YOU HAVE ANY IDEA when you last received a tetanus vaccine? Have you had two doses of hepatitis A vaccine? Could you provide the documentation for either? Most of us would answer no to at least one of these questions, yet our immunization record may be very important for both our personal health and for the health of the community (e.g., during an outbreak). We are in the medical field, so think about how many of your patients can easily put their hands on their immunization record.

The solution to this frequent problem is available — it’s the San Diego Immunization Registry (SDIR). SDIR is a secure,

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web-based central repository for immunization records that is maintained by the San Diego County Health and Human Services Agency. SDIR has existed for nearly 20 years, and recently it has become even more accessible to all healthcare providers in San Diego County. One good thing that electronic health records have unveiled is the ability to exchange health information behind the scenes and without taking any time. You may not know it, but SDIR is either already interfacing with your EHR or is about to be. These linkages will allow you to find a patient’s immunization record with the push of a button, and

also allow additional shots you administer to be recorded in SDIR. SDIR currently contains immunization data on 2.5 million people and is linked to many EHR systems, either directly or through San Diego Health Connect, our local health information exchange. SDIR is the secure, web-based way for you to access immunization data.

The most frequent use of SDIR is simply to verify past immunization history for patients who are new to your practice and for whom you don’t have a complete record.

Having your system linked to SDIR will save staff time in updating your records and keep you from giving unnecessary,

duplicative vaccines. This function is particularly valuable if you take care of highly mobile populations. A perfect example of the utility of SDIR is the massive effort to provide hepatitis A vaccine to control our current outbreak of hepatitis A in the homeless population. Vaccine outreach efforts have been extensive, and conducted by many different provider organizations — which is a good thing — but it has led to duplicate vaccinations because, in several cases the patient doesn’t know for sure whether they’ve already been immunized.

A more routine scenario is a patient presenting to an emergency department or urgent care with a tetanus-prone injury and a decision needs to be made whether this patient needs a Td booster. It is the rare patient who is going come to that visit with their immunization record in hand. Once linked to SDIR, you will be able to easily obtain the tetanus immunization history on this patient and make the right decision

about the need for addition immunization.

SDIR also has a number of features that can improve your clinic’s routine immunization practices. SDIR can analyze an immunization history and provide a list of vaccines that are due that day. This also saves staff time, since the immunization schedule for both children and adults has become quite complex. Do you remember the difference in dosing interval for varicella vaccine for children 12 years of age or younger compared to those 13 years and older? SDIR can save you from looking that up, as the system will tell you if a dose is due today. SDIR can generate a list of patients that are about to be due for vaccines, or a list of your patients that are overdue for vaccines. This would facilitate providing reminder and recall messages, which have been shown to improve immunization coverage rates. SDIR is the perfect tool for quality improvement projects to improve vaccine delivery. SDIR also produces

reports on immunization practices for your clinic and can help manage your vaccine inventory.

The Immunization Program, in the County of San Diego Health and Human Services Agency, is working with its vender and San Diego Health Connect to gradually connect all the large healthcare systems in San Diego County to allow SDIR to reach its full potential. The linkages don’t stop at the County border. There are immunization registries in every county and state, so in the near future you may be able to make informed immunization decisions for your patients regardless of where they have received prior vaccine. The information will be stored in the cloud for you to access this information whenever you need to for optimal patient care.

For more information on SDIR, please visit http://www.sdiz.org/CAIR-SDIR/ index.html or call the SDIR Helpdesk at (619) 692-6655.

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13

R I S K M A N AG E M E N T

PHYSICIANS CAN BE AT RISK WHEN HOMEBOUND PATIENTS REFUSE HELP

By Robin Diamond, MSN, JD, RN

PHYSICIANS ARE FOCUSING more than ever on treatment plans that include providing patients the kind of care they need at home. There is real danger if instructions are not followed and resources are not used: Physicians face potential liability when patients refuse the help that is offered or simply neglect to follow up as instructed.

Even a verdict in favor of the physician does not negate the time, expense, and emotional impact of being sued. Consider this example: A 67-year-old male with a history of obesity, hypertension, hypercholesterol, atrial fibrillation, and cardiovascular disease had seen the same physician for 20 years.

During one hospitalization, the patient was put on the blood thinner Coumadin. The physician and the discharge nurse both educated the patient and his wife about the risks of Coumadin use and the importance of having blood work done every month.

Nevertheless, the patient did not keep the first appointment for the monthly blood test (INR). The physician’s staff

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called him to schedule a follow-up visit, but the patient did not return the call. Two days following the call from the physician’s practice, the patient fell at home. His wife took him to the emergency department, where she told the emergency staff that she had been unable to drive him to his appointment for blood work, but she had made sure he took his Coumadin as prescribed. The patient’s INR was extremely elevated, with a reading of 8.8. The patient was diagnosed with a bilateral subdural hematoma and underwent a bilateral craniotomy. He was discharged to home, but due to problems with his coordination and confusion, he visited the emergency department several more times over the next few months.

Subsequently, the patient sued the physician for malpractice, claiming that the physician failed to properly manage the medication regimen and failed to monitor the blood levels, resulting in the fall, subsequent injury, and poor recovery. He also claimed

the doctor failed to warn him of the risk of bleeding from the Coumadin.

The case went to trial. Because of the doctor’s thorough documentation, the jury agreed that he had properly educated the patient and made the right resources available to monitor the effects of the Coumadin.

The jury found that the patient’s failure to schedule his lab appointments and follow-up appointment caused the injury and, therefore, found in favor of the physician.

While this patient failed to follow physician instructions, other homebound patients simply refuse any help. A recent study found that between 6 percent and 28 percent of patients eligible for home healthcare refuse these services, for various reasons, and similar trends are seen with other types of assistance for patients at home. Patients often say they are managing just fine and don’t need any help, while others don’t want strangers coming into their homes or worry about the cost of copays for home care. That means some patients are not getting the follow-up and supportive care that the doctor outlined in the care plan. And when a patient doesn’t follow up, it can put the physician at risk.

Patient behaviors were contributing factors in 25 percent of internal medicine closed claims studied by The Doctors Company. Of these factors, noncompliance with the treatment plan was the most common, accounting for 9 percent of internal medicine claims.

This was followed by 7 percent of claims resulting from patients failing to make a follow-up appointment or referral, and 4 percent of claims resulting from patients failing to take medications as prescribed.

The potential malpractice risks to physicians are increasing as more care is moved from a healthcare setting to the patient’s home. Patients discharged from a hospital typically benefit from a comprehensive discharge program that includes nurses and social workers, but those going home from a clinic or doctor’s office may not. In those situations, it is imperative for the doctor to have policies and procedures that ensure the patient is properly educated on what is necessary for improvement, maintaining health, and managing chronic conditions.

The physician might be able to prove that the patient received proper instructions and that the necessary resources were available, but a plaintiff’s attorney can still argue that the patient was not capable of complying, or that it was the physician’s obligation to ensure that adequate home care was taking place.

The following are tips for physicians to keep in mind to reduce risks when treating homebound patients: • Conduct a risk analysis to determine how likely the patient is to comply with instructions. Consider the following: patient’s age; ability to drive; socioeconomic status; whether patient lives alone; and history of failing to comply with appointments or medication instructions.

• Document that: >> The homebound patient received proper discharge instructions — including information that is clear, understandable, at the literacy level of that particular patient, and in the patient’s preferred language. >> Resources were made available to overcome compliance challenges. For example, document which community resources were scheduled to provide the level of support needed by the patient. >> The physician or practice made a goodfaith effort to follow up and intervene if the patient was not in compliance.

This includes recognizing that the patient missed an appointment for lab work or a follow-up visit, and reaching out to reschedule. Each attempt to contact the patient should be documented in the record.

• Schedule the follow-up appointment before the patient leaves the office. Give the patient contact information for the community home-health resources to help with medication and to assist with transportation for follow-up care and lab testing. Ask home health resources to alert the practice if the patient fails to follow the treatment plan.

• Educate the patient about the reason community resources will be provided, and draw a distinction between what is and is not being offered. Some patients resist intervention because they envision a high level of home healthcare, which they may consider intrusive. If the patient does not need this level of care, make sure they understand that the home healthcare provider only intends to check medica-

tion usage and provide other compliance assistance.

• Explain to the patient why it is so important to follow instructions and accept the assistance offered to them. Patients highly respect what their physicians say, so hearing it directly from the physician often has more impact than receiving the same information from other healthcare providers.

Patients’ reluctance to follow the discharge plan is often caused by a lack of understanding about what type of follow-up care is needed. Taking time to document patient discussions not only gives homecare providers valuable information to assure the patient is following the plan, but will also demonstrate, in the event of a lawsuit, the high quality of care provided.

Ms. Diamond is senior vice president of Patient Safety and Risk Management, The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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17

F LU VAC C I N AT I O N S

FLU VACCINATIONS MANDATED FOR HEALTHCARE PERSONNEL

By San Diego County Health and Human Services Agency, Public Health Services

INFLUENZA VACCINATIONS FOR HEALTHCARE PERSONNEL How widespread is influenza (the “flu”)? Although influenza is a vaccinepreventable disease, each year close to 15% of the population becomes infected with the flu virus. In San Diego County, during the 2016–17 influenza season, 6,810 flu cases were reported, with 108 ICU cases and 87 deaths.

Why are healthcare personnel in San Diego County being asked to get a flu shot? Healthcare personnel and patients can infect each other with influenza in any healthcare setting. By getting vaccinated against the flu, health care personnel will help to protect patients who are at increased risk from influenza. Flu vaccination will also protect coworkers, patients’ visitors, and your family members at home.

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DECEMBER 2017

What is considered a healthcare setting? Healthcare settings include acute care hospitals, ambulatory and community clinics, emergency medical service agencies, long-term care and skilled nursing facilities, and private, physicians’ offices, urgent care centers, outpatient clinics, pharmacies, and home healthcare agencies.

Who are considered to be healthcare personnel? Healthcare personnel include physicians (e.g., private practice, healthcare systems), nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, and contract staff not employed by the healthcare facility.

Additionally, flu vaccines are recommended for people not directly involved in patient care, but those who are part of the healthcare setting and work as employees or volunteers

healthcare personnel have symptoms of influenza, they will have already exposed many patients. Staying home with a vaccine-preventable disease imposes additional burdens on coworkers that could be avoided.

As a manager in a healthcare setting, what can I do to protect my staff and patients against the flu? Promote, administer, and provide access to the annual flu vaccine to all healthcare personnel.

Encourage sick workers to stay at home and emphasize handwashing and coughing etiquette. Offer appropriate personal protective equipment (PPE), such as gloves, masks, and respirators. Limit transporting or moving infectious patients throughout the facility, and limit the number of healthcare staff members who come into contact with flu patients.

COMMON QUESTIONS ABOUT THE FLU VACCINE FOR HEALTHCARE PERSONNEL

in clerical, food service, housekeeping, laundry, security, maintenance, administration, and billing.

How would a flu shot benefit me? By vaccinating yourself against the flu, you increase the chances of a healthier flu season for yourself, patients, coworkers, and family.

You will miss fewer days of work and avoid feeling miserable from a high fever, fatigue, coughing, and other symptoms associated with the flu. Because individuals can be infectious with influenza for a day before they start to feel symptoms, healthcare workers who receive flu vaccine will be less likely to transmit the virus to vulnerable patients and visitors. Your decision to vaccinate supports higher quality of care standards for your organization as a whole.

Can’t I just wear a mask or stay home if I feel sick? Unfortunately, by the time

When should I get the flu vaccine? The Centers for Disease Control and Prevention (CDC) recommends getting the annual flu vaccine as soon as it is available, usually no later than November. Consider that it takes about two weeks after vaccination for antibodies to develop in the body and provide protection against the flu.

Which flu vaccine should I get? This season, only injectable flu vaccines (flu shots) are recommended. The nasal spray vaccine (Live Attenuated Influenza Vaccine — LAIV) is not recommended for use during the 2017– 18 season because of concerns about its effectiveness. Flu vaccines this season protect against three strains of the virus (trivalent has two A and one B strain) or four strains (quadrivalent has two A and two B strains) that are anticipated to be circulating in the community. The CDC has no recommendation or preference for any of the injectable flu vaccine products. The important decision for each person is to get vaccinated for the flu this year and every year.

Who should not get vaccinated?

People with severe, life-threatening allergies to flu vaccine or any ingredient in the vaccine (e.g. gelatin) should not take the vaccine.

Some people with a history of Guillain-Barré Syndrome (a severe paralyzing illness) should not get this vaccine. These conditions should be discussed with a healthcare provider.

Those with moderate to severe illness should speak with their provider before getting the flu vaccine. People with egg allergies, who only experience hives after exposure to egg, can get any licensed and recommended flu vaccine appropriate for their age and health.

People who have symptoms other than hives after exposure to egg should receive the age- and health-appropriate vaccine in a healthcare setting by a healthcare provider who is able to recognize and manage severe allergic conditions.

I’m pregnant. What should I be concerned about? It is very important for pregnant women to get the flu vaccination.

Pregnant women have a higher risk for serious complications from influenza than nonpregnant women of the same age. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness, hospitalization, and potentially death from influenza. Pregnant women with flu also have a greater chance of serious health conditions, including premature labor and delivery.

Flu vaccination helps protect women during pregnancy and their babies for up to six months after they are born. Quadrivalent nasal spray flu vaccine is not recommended for anyone during the 2017–18 season and is never recommended for pregnant women.

If you are pregnant, talk to your healthcare provider before your flu vaccination.

Where can I get more information about influenza and the flu vaccine?

Visit http://www.cdc.gov/flu/index.htm, a comprehensive website from the CDC dedicated to the seasonal flu. It particularly provides detailed information about the importance of getting the flu vaccine for healthcare professionals.

SAN DIEGO PHYSICIAN.ORG

19

Cannabis Hyperemesis Syndrome

TREATMENT GUIDELINES AND THE INTRODUCTION OF ‘SCROMITING’

By Roneet Lev, MD, FACEP

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DECEMBER 2017

The San Diego County Medical Society’s Emergency Medicine Oversight Commission (EMOC), led by Dr. Roneet Lev, MD, FACEP, identified a public health concern involving the increased cases of cannabis hyperemesis syndrome (CHS). CHS is a condition of cyclic vomiting and diffusive abdominal pain associated with cannabinoid overuse. A press conference was held on Nov. 30 at SDCMS offices to promote education to the public about CHS.

W

ith increased public exposure to marijuana, the health community needs to be ready to respond the public health challenges. The San Diego County Medical Society’s Emergency Medicine Oversight Commission, (EMOC), identified a public health concern with increased cases of cannabis hyperemesis syndrome (CHS). CHS is a condition of cyclic vomiting and diffuse abdominal pain associated with cannabinoid overuse. A new terminology that is a hallmark sign of CHS is “scromiting”: screaming plus vomiting. Patients often present to emergency departments repeatedly and undergo extensive evaluations, including laboratory testing, advanced imaging, treatment with opioids that lack evidence, and, in some cases, unnecessary procedures.

EMOC worked in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology to create a guideline to unite the ED community in the treatment of CHS. This guideline was shared and promoted at all San Diego emergency departments as well as in a medical publication led by Dr. Jeff LaPoint in the Western Journal of Emergency Medicine. While CHS typically presents in the emergency department, physicians across specialties encounter this condition.

The research and conclusions highlight key components of the publication as well as local and national data on marijuana.

Cannabis Data

• ED Visits in San Diego County with a primary and secondary diagnosis of cannabis increased by 830% from

1,108 cases to 10,302 cases.

• Cannabis Use Disorder as defined in DMS V affects 6 million Americans.

• Cannabis Withdrawal affects 44% of frequent users.

• Cannabis Addiction occurs in 9% of regular adult users and 17% of regular adolescent users.

•

•

Cannabis Hyperemesis Syndrome diagnosis

• Presentation: Abdominal pain, nausea, vomiting °° Pain generalized and diffuse in nature • Cannabis Use: Heavy, chronic, daily cannabinoid use °° Plant matter, vapes, waxes, synthetics °° Case reports with only edibles (new finding since initial publication) • Multiple ED visits for abdominal pain and vomiting with negative work-up • Course of Illness: °° Episodes typically last 24–48 hours, but can last as long as 7–10 days °° Symptoms may return with reexposure

Management

• Cannabis cessation is the only standard treatment in the current literature °° Avoid opioids (to avoid opioid addiction). °° If low suspicion for emergent etiologies or known/confirmed CHS, avoid advanced imaging, radiation, and invasive procedures.

• Supportive therapy includes: °° IV fluids for dehydration °° Antiemetics °° Benzodiazepines

• •

°° Antipsychotics: Haloperidol 5 mg IV/IM, Olanzapine 5mg IV Hot showers are beneficial, but caution patients regarding burns from hot water Apply capsaicin cream (available OTC) topically to abdomen or back of arms TID °° Caution: use gloves, wash hands thoroughly after application, and discontinue use if patient develops significant skin irritation or chemical burns. °° Caution near faces, eyes, nipples, perineum — can use occlusive dressings to cover and protect these areas (but do not cover capsaicin with occlusive °° dressings or use on broken skin); °° 0.075% concentration (may cause initial discomfort) °° Can be used as first-line treatment in cases of clear diagnosis Provide education, reassurance, and referral to cessation programs.

Use clear documentation in the medical record for possible future visits. °° Document the word “Cannabis” or “Marijuana” in the diagnosis.

References

• LaPoint J, et al. Cannabis Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline, WestJEM, November 2017. https://escholarship. org/uc/item/59z5q826 • Office of Statewide Health Planning and Development, Emergency Department Discharge Database 2006–2014 • CDC: Marijuana and Public Health https://www.cdc.gov/marijuana/ health-effects.htm

SAN DIEGO PHYSICIAN.ORG

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M AC R A

THE QUALITY PAYMENT PROGRAM: WHAT YOU NEED TO KNOW FOR 2018

by Beth Hickerson, Quality Improvement Advisor, Medical Advantage Group

ALMOST A YEAR AGO, Congress established the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

While designed to improve patient health outcomes, encourage practices to spend wisely, minimize the burden of practice participation, and be fair and transparent, the program has been difficult for many medical practices to implement.

The government recently announced 2018 changes to this program. But don’t be dismayed. Many of these changes add flexibility and higher exemption requirements—welcome news to medical practices.

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DECEMBER 2017

Medical practices will be most affected by changes made by the Centers for Medicare and Medicaid Services (CMS) to the Merit-Based Incentive Payment System (MIPS), one of two QPP tracks. Some of the major changes to MIPS that practices should be aware of are: 1. Category weights have changed, even though the four reporting categories and requirements remain the same: • Quality: 50 percent • Advancing Care Information: 25 percent • Improvement Activities: 15 percent • Cost: 10 percent

2. Important general MIPS changes/ updates include: • Performance threshold to avoid penalties increased from 3 points to 15 points. This can be achieved solely by maxing out points in the Improvement Activities category.

• Virtual groups participation option offered. Virtual groups are composed of solo practitioners and groups of 10 or fewer eligible clinicians (eligible to participate in MIPS) who come together “virtually” with at least one other such solo practitioner or group to participate in MIPS for a performance period of 12 months.

• Low-volume threshold increased. More small practices and eligible clinicians in rural and Health Professional Shortage Areas (HPSAs) are exempt from MIPS participation. ° 2017 threshold: </= $30,000 or 100 patients ° 2018 threshold: </= $90,000 or 200 patients • Five bonus points added to the final score of clinicians in small practices. These points will be added automatically for providers in practices with 15 or fewer clinicians.

• Up to five points added to the MIPS final score for providers caring for complex patients.

CMS will use a combination of Hierarchical Condition Categories and counts of dually eligible patients (Medicare and Medicaid) to assign a complex patient bonus to the MIPS final score for applicable providers.

• Extreme and Uncontrollable Circumstances provision added for providers impacted by natural disasters. In 2017, providers in identified areas (e.g., hurricanes Harvey, Irma, and Maria) will automatically avoid a penalty for payment year 2019 without submitting any performance data. Beginning in 2018, providers must submit a hardship exception application to qualify.

3. MIPS Quality category changes have taken place: • Quality reporting period increased to 12 months. Providers must be ready to start tracking quality measure data on January 1, 2018, to fully report in the Quality category in 2018.

• MIPS performance improvement incorporated in scoring quality performance. Up to 10 points will be added to the Quality category score for statistically significant performance improvement at the category level between 2017 and 2018.

• Data completeness standards increased to 60 percent. Providers submitting quality measures via claims must report on at least 60 percent of their Medicare Part B patients. Providers submitting via registry, QCDR, or Electronic Health Record (EHR) must report on at

least 60 percent of all denominator eligible patients, regardless of payer.

No changes for CMS web interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS submission methods.

• Minimum scoring on measures that do not meet case minimum standards reduced to one point for large practices (16 or more providers).

• Caps on scoring limits on “topped-out” measures have changed. Six “topped-out” measures have been given a cap of seven performance points, rather than 10.

4. MIPS Advancing Care Information category changes have occurred: • Incentives added to encourage the use of 2015 edition Certified Electronic Health Record

Technology (CEHRT). Providers have been given a full year extension on the use of 2014 CEHRT and can continue to report the 2017 Advancing Care Information Transition Objectives and Measures.

However, providers who elect to use 2015 edition CEHRT in 2018 will earn bonus points.

• Exclusions added for the E-prescribing and Health Information Exchange base measures. Individuals or groups with fewer than 100 patients in the denominator for these measures may claim an exclusion and not report them. These new exclusions are retroactive to the 2017 reporting year.

• New Advancing Care Information hardship exception added for clinicians in small practices. Practices with 15 or fewer eligible clinicians can apply to have

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M AC R A

their Advancing Care Information category score re-weighted to the Quality category.

• New Advancing Care Information hardship exception option added for clinicians whose EHR was decertified.

• Automatic re-weighting of the Advancing Care Information performance category score to Quality added for ambulatory surgical center (ASC)-based MIPS eligible clinicians. This change will be retroactive to the 2017 performance year.

5. MIPS Improvement Activities category changes have been made: • Total number of approved Improvement Activities increased from 92 in 2017 to 112 in 2018.

• Additional CEHRT-related Improvement Activities made available. This increases options

for earning Advancing Care Information bonus points.

• Patient-Centered Medical Home (PCMH) certification threshold changed for full Improvement Activities credit.

Tax Identification Numbers (TINs) must have 50 percent of their practice sites certified as PCMHs to receive automatic full credit in the Improvement Activities category.

6. MIPS Cost category changes have occurred: • Episode-based measures eliminated from the Cost category score calculation. Only Total Per Capita Cost and Medicare Spending per Beneficiary (MSPB) measures will be used to calculate the Cost score.

• Automatic re-weighting of Cost score to Quality added for clinicians who do not meet minimum case standards

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DECEMBER 2017

requirements. Individuals and groups who do not receive a Cost score because they do not have enough attributed patients for either Cost measure will automatically have their 10 percent Cost points re-weighted to Quality.

• Improvement scoring added for Cost. Individuals or groups who demonstrate statistically significant Cost improvement between 2017 and 2018 will receive up to 1 percent added to their Cost category score.

Practices that find these changes overwhelming may want to reach out for expert help with industry-leading best practices to maximize Medicare payments—visit medicaladvantagegroup. com for more information. For resources on MACRA and being successful in optimizing reimbursement, go to thedoctors.com/ MACRA. Contributed by The Doctors Company (thedoctors.com)

CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED WE ARE LOOKING FOR VOLUNTEERS TO PARTICIPATE IN CLINICAL TRIALS: Currently enrolling volunteers who suffer from rheumatoid arthritis, lupus, psoriasis, and psoriatic arthritis. Qualified volunteers may receive: no-cost investigational study medication, no-cost study-related care from a study doctor.

There is compensation available for time and travel. All study-related care will be at no cost, and volunteers can continue seeing their primary care doctor during the study. Health insurance and doctor referrals are not required to participate.

Please email Joy at joy@rheumSD.com for more information. [607] PHYSICIAN POSITIONS AVAILABLE PART TIME PHYSICIAN: Progressive Medical Specialists is an outpatient medication assisted treatment program located in San Diego, CA. We are currently in need of a part-time Physician to work 1 - 3 days per week. The Program Physician is responsible for providing the day-to-day medical care and treatment for all program patients. The Program Physician performs all duties in compliance with the California Code of Regulations for Narcotic Treatment Programs.

Training is provided. Please send your CV to tboylan@pms911.com or call 619-286-4600. 12/5 OB/GYN POSITION AVAILABLE: A MultiSpecialty Group is seeking a full-time OB/ GYN must be BC/BE to join a busy OB/GYN and Uro-gynecology practice, group of a physician and a nurse practitioner. Located in Southern California 1 ½ hours East of San Diego and Palm Springs; We offer a Competitive compensation, full benefits and opportunity for partnership. If interested, please e-mail CV to ekmoukarzel@aol. com or fax to : 760-352-6221. Visit our website: www.feminacareouro-gyn.com for additional information on our practice. 11/30 INTERNAL MEDICINE POSITION AVAILABLE: Unique opportunity to practice outpatient internal medicine in beautiful North San Diego County. Practice is part of a well-established internal medicine group with a long history of outstanding care in the community, seeking physician who enjoys providing thoughtful, personalized patient care. Exceptional office staff, small group environment, autonomy and very high quality patient care are among the many benefits of this opportunity. Office is located near San Diego coastal communities, accessible from all parts of San Diego County as well as Orange County.

Seeking BC/BE applicants. Please send CV to portofino3@aol.com or call 619-248-2324. 11/2 PRACTICE/INTERNAL MEDICINE PHYSICIAN wanted for established private office in San Diego. La Jolla Village Family Medical Group has been caring for patients of all ages for 28 years in the UTC/La Jolla area of San Diego, adjacent to the UCSD campus. We provide

PART TIME OR FULL-TIME SUB-INVESTIGATOR Work under the supervision of the Medical Director/Principal Investigator performing a variety of scientific clinical research activities to include the direct assessment of study participants and execution of protocol specific procedures.

Required Education and Experience: M.D., Board Certification (or Board eligible) in Internal medicine, Family practice or Emergency Medicine, Skills/Competencies: Excellent professional communication, punctual and responsible, friendly and outgoing demeanor, must demonstrate a passion for direct patient interaction.

Demonstrate clinical competence, positive leadership and ability to work collaboratively with a multidisciplinary team. Send resume to: eliku@artemis-research.com comprehensive preventive medicine, illness management, travel medicine, sports medicine, evidence based chiropractic care, weight management, and more. Call responsibilities minor, hours consistent with healthy work/life balance. Friendly and upscale environment.

Cohesive team. This a real family practice. Boardcertified, California licensed MD and DO physicians interested in this opportunity should send CV to: triciaberkoff@gmail.com. 10/20 MULTI-ETHNIC GROSSMONT PEDIATRICS [private practice] in East San Diego seeks BC pediatrician, with 4+ years experience. Patientengaged and clinically-interested in Obesity, ADHD and Asthma, and in care continuity.

Grossmont Pediatrics has 20+ years reputation for family-oriented care and teaching parents.

Office schedule 3 days per week is ideal for dedicated pediatrician wishing to balance work and personal life, while still nurturing close physician-patient relationships. Salary $81,000 for BC pediatrician + $6,000 one hospital rounding and light after-hours call. Hospitals’ privileges, AAP, CME fees, tail-coverage included liability insurance included. Contactvenk@gpeds. sdcoxmail.com or 619-504-5830. 10/10 SEEKING A FULL/PART TIME DERMATOLOGIST to join a co-op situation at a brand new Medical and Day spa. Share space with two Licensed Massage Therapist and Esthetician in a new start up office on Miramar Rd/805. Opportunity to do Cosmetic, Cool sculpting, Botox, Fillers, and Laser procedures.

3,000 sq ft office with reception area, lobby, kitchenette, bathroom. Free parking, handicap access. Short term or up to a 5-year lease available. $1,300/per month. Have 3 extra large offices available. Please call 760-815-3236 or email me at mpear4560@gmail.com 9/4 FAMILY MEDICINE POSITION AVAILABLE: The Sycuan Medical Dental Center is a tribal

TO SUBMIT A CLASSIFIED AD, email Editor@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

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DECEMBER 2017

health center, located on the Sycuan Indian Reservation in El Cajon, CA. This is a full-time position to provide outpatient care, no OB. Current CA and DEA licenses required. Student loan repayment possible. Must be BC/BE. Competitive compensation, full benefits. If interested, please e-mail CV to Amy Laughner (ALaughner@sycuan. com) or apply online at www.sycuan.com. 7/21 PRACTICE FOR SALE FOR SALE. BUSY FAMILY PRACTICE POTENTIAL URGENT CARE: Established family practice for 27 years located in Chula Vista near H Street at 805 in upscale mall setting. Ideal location with free and easily accessible parking. Spacious 2600 ft. office space with CLIA Certified Lab and X-ray.

Practice accepts and experienced in billing: Medicare; Tricare, Immigration Exams, DOT Certification; Workers Comp. Contact: S.J.Anderson (858)736-5818 or Email: marva. winchi.garcia@gmail.com 11/3 UNIQUE MEDICAL SPA FOR SALE-OWNER RETIRING Committed clientele, growing revenues/profits p lus expansion possibilities.

Bank pre-approved for SBA financing. Offered at $999,000 by Transworld Business Advisors of San Diego Central (CalBRE#02019152). Contact Robert Cunio MBA, (888) 604-8221/rmcunio@ tworld.com 10/11 OFFICE SPACE / REAL ESTATE AVAILABLE LA JOLLA/GOLDEN TRIANGLE. Windowed office in Class A building in UTC area (furnished or unfurnished) easily accessible to UCSD. Scripps, Biotech Industry, I5 and 805. ADA compliant. Our offices provide both psychiatric and psychological services and inter referrals are a plus. We have a strong association with the Student Health Center and Psychological Services at UCSD and with Scripps Health. Billing is available.

Available January 1, 2018, either part-time or full-time. Reasonable rates. Please contact either Deirdre Elliott, M.D. at 858 452 3882 or Sallie Hildebrandt, Ph.D. at 858 453 1800.

SOUTH BAY: Available for monthly sublease; pulmonary specialist for busy practice in South Bay. This is a great sublease opportunity for pulmonologist. If interested, call: 619-585-0476.

Ask for Judith. 11/3 SCRIPPS ENCINITAS CAMPUS OFFICE to share starting Jan.1. It is a beautifully decorated, 1600 sq.ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and 1/2 mile from Swami’s beach.

Contact Kristi or Myra 760-753-8413. View space on website: www.eisenhauerobgyn.com. Looking for compatible practice types. 11/3 LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genessee Ave. – great location by the front of the main entrance of the hospital between I-5 and I-805. Multidisciplinary group

MEDICAL EQUIPMENT / FURNITURE FOR SALE

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp & Rady Children’s. Ready-to-occupy suites ranging from 1,300-5,000 SF with mix of exam rooms and offices. Will consider short-term & long-term leases.

For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org

CLASS “A” MEDICAL OFFICES, VISTA

Grow your business and upgrade to a new Class “A” medical office in TriCity’s leading outpatient health center.

Collegial environment with more than 40 physicians in 15+ specialities.

Strong primary care referral base. Fully renovated offices with today’s modern finishes. Close hospital proximity.

Multiple sizes available ranging from 1,200-6,800 SF. For more information, including floor plans, please call Greg Petree at (858) 792-0696 x112 or visit www.vistamedicalplaza.com/leasing

and available to any specialty. Note we are in great need of a psychiatrist. Excellent referral base in the office and on the hospital campus.

Please call (858) 455-7535 or (858) 320-0525 and ask for the Sandy. 10/23 LA MESA OFFICE SPACE AVAILABLE. East County San Diego. Spacious 4,675 square foot office space to sub-let.Specialist suite.Recently updated.10 exam rooms. Two waiting rooms.

Main waiting area is newly renovated. Three in-suite restrooms. Diagnostic lab/service rooms.

Conference/ lunch room. Lots of storage space.

Large patient parking lot (free) with ample space.

Walking distance to Grossmont Hospital. Centrally located in East County. Please contact Jennifer Hansen at lamesacardiac@yahoo.com or cell 619249-8154. 10/10 SHARED OFFICE SPACE: Very attractive 3 exam room, medical office near Alvarado Hospital.

Available for 1, 2 or 3 days per week. Reasonable rates. Call Pat at 858-344-5020. 10/10 MESA MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE: 1500 sq.ft Frost Street office with 2 exam rooms, 2 offices, front office area, bathroom, kitchenette and lobby. Easy access to Sharp Memorial Hospital and Rady Children’s Hospital and the 163 and 805 freeways. Up to 4 month lease with possible extension. Please call (858)467-1899. 8/3 POWAY OFFICE SPACE AVAILABLE PARTIME: Spacious 5 exam room office including large treatment room. Located across the street from Palomar Medical Centery Poway (aka Pomerado Hospital). Well suited for surgical or medical specialty. Contact bmorales@genhp.com. 7/21

USED OFFICE FURNITURE FOR SALE: Exam tables, stools, chairs, x-ray view boxes, executive desk, waiting room chairs, tables, filing shelves and cabinets. Please call (858)467-1899. 8/3 NONPHYSICIAN POSITIONS AVAILABLE PART TIME PHYSICIAN ASSISTANT: Looking for a part time Physician Assistant for a rheumatology office in Escondido. 20-30 hrs a week. Spanish desired. To start as soon as possible. Please send resume and references to info@rheumSD.com. 12/5 MEDICAL ASSISTANT IN BUSY RHEUMATOLOGY OFFICE. FULL TIME. Wonderful opportunity for learning and growth.

We are looking for someone who is organized, capable of multi tasking, takes instruction well, and has a positive helpful attitude.

Tasks include, but are not limited to: Front desk answering phones, make calls to patients, collect fees, set appointments and filing.

Back office: Rooming patients and taking vitals, helping with therapy, keeping things organized and running smoothly, and cleanup.

Spanish desired. Salary is based on experience.

Please email info@rheumSD.com 11/30 SEEKING A DYNAMIC BUSINESS OFFICE MANAGER for a busy medical practice located on Convoy Street, close proximity to the 163/805 freeway. Responsible for the overall operations of the medical practice and reports directly to the CEO. This position ensures that the medical practice is running smoothly, effectively and efficiently rendering a high standard of quality and customer service.

Accountable for operational systems, processes and policies in support of the organization’s mission. Required Education and Experience: Requires at minimum 3 years of significant work related experience in a private or group medical practice setting; supervised at least 10 F.T.E.’s

and ability to collaborate with a minimum of 4 physicians in a practice setting. Preferred Education and Experience: AA or higher in Health Management or Business Administration education; Familiarity with health care laws, regulations and standards; Proficient in Excel and Word. We are offering a competitive salary, excellent benefits. Please email resume to businessofficemanager2017@gmail.com. 11/3 POSITION AVAILABLE FOR DYNAMIC NURSE PRACTIONER OR PHYSICIAN ASSISTANT to join our team of Women Healthcare providers specializing in Reproductive Medicine. We are offering a competitive salary, excellent benefits and a flexible schedule. Requirements: Obtain detailed medical history, review medical records, and collaborate with physician in developing a thorough infertility evaluation and treatment plan. Perform transvaginal sonograms for follicular measurements and collect data to monitor IVF cycles. Perform early OB ultrasounds and monitor early preganancy lab values. Master’s in Nursing or equivalent. 2-4 years experience in OB/GYN. Fertility experience preferred. Please email klopez@cacrm.com or call 760-274-2000. Visit our website at cacrm.com. 8/25 PRODUCTS / SERVICES OFFERED PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

PLACE YOUR AD HERE Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org

SAN DIEGO PHYSICIAN.ORG

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Secured over $1 billion annually to improve provider payments and graduate medical education funding.

ONEBILLION

Defended medical staff independence in “existential threat” lawsuit against the Tulare Regional Medical Center.

ONEMILLION Recouped nearly $1 million from payors on behalf of physician members.

Expanded member insurance program with state-approved workers comp coverage, new cyber liability program and personal insurance products.

CMA executive awarded “CFO of the Year” for fiscal responsibility and innovative strategic investments.

Defeated irresponsible federal legislation that would have harmed patient access to physicians and decreased health care coverage.

Stood in solidarity with California’s “Dreamers” and in support of diversity and inclusion.

Reaffirmed staff commitment to CMA’s mission by developing a credo.

Developed AB 72 and MACRA resource centers to educate members on rights and responsibilities.

Convinced CMS to further reduce 2018 MACRA reporting burdens.

Debuted a Mother’s Room at CMA headquarters for breastfeeding staff and members.

Declared firearm violence “violates the fundamental human right” to “live safely without fear in a free society.”

@cmaphysicians www.cmanet.org 28

DECEMBER 2017

Headquarters 1201 J Street, Suite 200 Sacramento, CA 95814 (916) 444-5532

CMA Member Service Center Just one number to call for all your CMA needs!

(800) 786-4CMA (4262)

t hank you

INSURANCE

TO OUR ADVERTISERS WHO HAVE SUPPORTED SAN DIEGO PHYSICIAN MAGAZINE THIS YEAR.

The Doctors Company (800) 852-8872 www.thedoctors.com/SDCMS Cooperative of American Physicians, Inc. (800) 356-5672 www.CAPPhysicians.com Norcal Mutual Insurance Company (844) 4NORCAL www.norcalmutual.com

BANKING

First Republic Bank (855) 886-4824 www.firstrepublic.com

CELL PHONE SERVICE Sprint (866) 639-8354 www.sprint.com/ healthcarediscounts

COMMERCIALREAL ESTATE

JLL Healthcare Practice Group (858) 410-6377 www.sdmedicalrealestate.com North Coast Medical Plaza northcoastmedicalplaza.com

EDUCATION

Practicing Physicians Approach to the Difficult Headache Patient (312) 867-9104 www.dhc-fdn.org

EMPLOYMENT

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Please contact these vendors for your business needs.

Additional information can be found at the Practice Management Resources page at www.SDCMS.org.

Artemis Institute for Clinical Research (858) 278-3647 www.artemis-research.com

Tracy Zweig & Associates (800) 919-9141 www.tracyzweig.com

MEDICAL BILLING

Medical Billing Strategies (619) 260-0999 askmbs.com Valley Medical Billing Services (800) 807-9843 valleybillingservices.com

MORTGAGE BANKING

Bank of America billy.cafcules@bankofamerica.com ed.woolery@bankofamerica.com

PAIN MANAGEMENT

Whole Bodied Consulting (619) 733-5344 wholebodied.com/physician

PRACTICE MANAGEMENT Absolute Solutions (858) 256-0351 www.abs-sol.com

PRESCRIPTION DISCOUNTS California RX Card CaliforniaRxCard.com/app

TECHNOLOGY

Soundoff Computing (858) 569-0300 www.soundoffcomputing.com

Vista Community Clinic (760) 631-5000 www.vistacommunityclinic.org

SAN DIEGO PHYSICIAN.ORG

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$5.95 | www.SANDIEGOPHYSICIAN.org

San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, Ca 92123

PRSRT STD U.S. POSTAGE

PAID DENVER, CO PERMIT NO. 5377

[ Return Service Requested ] 6316_ACC_Cardiology_PD_Feb2017 FP 4C Final Trim: 8.187” x 8.615” Bleed:0.25” deliver to jrohr@sdcms.org NO BORDER, WITH BLEED

Tirelessly defending the practice of

GOOD MEDICINE. We’re taking the mal out of malpractice insurance.

By constantly looking ahead, we help our members anticipate issues before they can become problems. And should frivolous claims ever threaten their good name, we fight to win—both in and out of the courtroom. It’s a strategy made for your success that delivers malpractice insurance without the mal.

See how at thedoctors.com