April 2016

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

DIGITAL HEALTH Web-Based Disease Management

EHRs in the ER Concerns About Medical Errors

Social Media Bridging Disparities in Behavioral Health

Data Security Telehealth What You Should Know

Medical Apps: Buyer Beware Plus: SFMS Advocacy Update - Tobacco and Sugar

VOL.89 NO.3 April 2016

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IN THIS ISSUE

SAN FRANCISCO MEDICINE April 2016 Volume 89, Number 3

Digital Health FEATURE ARTICLES

MONTHLY COLUMNS

10 The Future of Care: Web-Based Comprehensive Disease Management

Bertha L. Long, MPH, Michael Aratow, MD, FACEP,

CMIO, David Pating, MD, FASAM

4

Membership Matters

7

President’s Message Richard Podolin, MD

13 EHRs in the ER: As Doctors Adapt, Concerns Emerge

About Medical Errors

Shefali Luthra

18 Classified Ads

11 Social Media: Bridging Disparities in Behavioral Health

Kim Norman, MD

16 Data Security: The Dawn of Digital Medicine

Tiffany I. Leung, MD, MPH, FACP 17 Telehealth: What You Should Know

Brittan Durham, MD

19 Buyer Beware: A Warning About Medical Apps

Satish Misra, MD

OF INTEREST

21 The New CDC Opioid-Prescribing Guidelines 22 SFMS Advocacy Update

John Maa, MD

23 Support for Increasing California’s Tobacco Tax

Kerin Arora, MD, Brian Goudy, MD, and Meredith Laguna, MD

24 CMA Leaders Advocate Physician Issues in Washington, DC

Elizabeth McNeil 25 Medicare Reimburement for Advance Care Planning

Jeff Newman, MD and Steve Heilig, MPH

27 Federal Task Force Takes Major Step to Unite Care of

Body and Mind

Sandra R. Hernández, MD Editorial and Advertising Offices: 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

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Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

24 Welcome New Members 28 Medical Community News 30 Upcoming Events

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Endorses Local Soda Tax Proposal The SFMS board of directors has unanimously endorsed the proposal to institute a penny-per-ounce soda tax in San Francisco. Public signature-gathering for this proposed legislation is currently underway.

The rise in obesity among both American children and adults presents a looming health disaster, but also an economic one. Obesity, diabetes, heart disease and more are linked to overconsumption of sugar. Soda is a leading source of dietary sugar, and these problems are steadily worsening. Forty-one billion dollars are spent treating obesity in our state annually. Soda taxes can not only decrease consumption, but the revenues may be used for education to prevent overconsumption and to treat related conditions.

The tax would be levied on beverage distributors, not consumers. A fifteen-member Sugar-Sweetened Beverage Tax Advisory Committee, including physicians, would advise the mayor and supervisors “to fund programs to reduce the consumption of sugar-sweetened beverages in San Francisco and to address the effect of such consumption.”

The soda industry is a multi-billion-dollar interest that spends hugely to market soda, and is expected to mimic the tobacco industry in its opposition to this proposal. They spent over nine million dollars to defeat it last time. Respected medical and public health voices are crucial in such battles, and the SFMS is proud to join in this effort on behalf of patients and the public. For more information, visit http://bit.ly/1nDq8QV.

port of the legislation at February’s public comment session to ensure bill passage. Long experience and much research indicates that perhaps the most important preventive goal with regard to decreasing tobacco use is to delay the onset of use as long as possible. Ninety percent of tobacco users start before age twenty-one, and if such use can be prevented, the young adults are unlikely to start. San Francisco joins New York City and Boston to raise the minimum age to purchase cigarettes and other tobacco products, including e-cigarettes.

The ordinance will go into effect on June 1. SFMS would like to applaud Mayor Ed Lee and Supervisors Scott Weiner, Eric Mar, Malia Cohen, and Mark Farrell for their leadership in championing sound public health policies.

CMS Extends Medicare Meaningful Use Exemption Application Deadline to July 1

The Centers for Medicare and Medicaid Services (CMS) has extended the deadline for physicians to file applications for hardship exceptions from the meaningful use requirements of the electronic health record incentive payment program. The new deadline is now July 1, 2016.

CMS also released new “streamlined” hardship exception application forms “that reduce the amount of information that eligible professionals must submit to apply for an exception,” the agency said. The new application forms and instructions on filing a hardship exemption can be accessed at https://www.cms. gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html.

SFMS is encouraging all physicians subject to the 2015 Medicare meaningful use program to apply for the hardship exception. CMS has confirmed that applying for a hardship exception will not prevent you from receiving the incentive payment if your practice successfully attests to having met the requirements. Filing for the exception will simply prevent your practice from receiving the meaningful use penalty in 2017 (based on the 2015 reporting period).

California’s End of Life Option Act Goes Into Effect June 9; Resources for Physicians

San Francisco Raises Tobacco Buying Age to 21 Legislation that would increase the legal age to buy tobacco in San Francisco from 18 to 21 was signed into law by Mayor Ed Lee on March 11. Authored by Supervisor Scott Wiener, the Tobacco 21 ordinance was endorsed by the San Francisco Medical Society, and SFMS members provided testimony in strong sup4

California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” was passed in October 2015 and permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. It will go into effect on June 9, ninety days after the conclusion of the special legislative session on health care. The California Medical Association (CMA) has released a new on-call document to help physicians understand ABX2-15. The fifteen-page guide offers FAQs, out-

SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

lines documentation and forms required to adhere to this legislation, and can be accessed at http://bit.ly/1navlzN. At the urging of the SFMS, CMA removed its longstanding opposition to physician aid-in-dying in May 2015.

SFMS presented both surveys of physician opinion and the reassuring evidence from other states to successfully advocate that CMA become neutral on the bill and topic, thus allowing the legislation to reach Governor Brown.

April 2016

Under California law, all individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate) must register to use the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016. SFMS compiled a FAQ to familiarize physicians with the registration process and key features of the newly upgraded system in the January 2016 issue of San Francisco Medicine. The information is also available at http://bit.ly/1OJhnfc. Physicians who experience problems with the new system should contact the DOJ CURES Help Desk at (916) 227-3843 or cures@doj.ca.gov.

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD

Reminder: CURES Registration Deadline Extended to July 1

Anthem Blue Cross to Require Member ID Numbers on Medical Record Submissions

Effective January 1, 2016, Anthem Blue Cross is requiring that all submission of patient medical records indicate the corresponding Anthem member identification (ID) number. According to Anthem, the new requirement will aid in identifying submitted medical records and reduce the number of repeat requests for medical records.

Practices submitting medical records should indicate the member ID number exactly as it appears on the Anthem member ID card (including the prefix) on the first page of each medical record submission. Anthem will attempt to match the ID number to the associated member in its system.

Practices submitting medical records without the member ID number indicated, or where the ID number cannot be identified, will receive a letter from Anthem advising that the member cannot be identified and requiring the provider to resubmit the documentation with the member ID number.

Update Your Practice Information for the SFMS Online & Print Pictorial Directory

Spotlight your practice and expand your referral base with an updated member profile! With the SFMS online Physician Finder and print directory, physician members have the opportunity to promote their practices on customizable individual web profiles and connect with a larger patient and referral base. SFMS has mailed out notifications to all physician members currently engaged in the practice of medicine to update contact information for the directory. If you did not have your picture in the 2015 directory, or if your information is outdated, we encourage you to update your directory entry by contacting SFMS at ayoung@ sfms.org or (415) 561-0850 extension 200.

Promote Your Practice with the SFMS Directory

If you would like to reach 1,000 health care professionals in San Francisco, please consider placing an ad in the 2015 SFMS Member Directory.

Members are eligible for an exclusive discount on quarter-page vertical ad placements. Advertising rates start at $395. To obtain the ad rate and contract agreement, contact Ariel Young at ayoung@sfms.org or (415) 5610850 extension 200.

WWW.SFMS.ORG

Volume 89, Number 3 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc

SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

APRIL 2016 SAN FRANCISCO MEDICINE

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Hilton San Francisco Union Square

May 13 - 15, 2016

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Health care power players will share strategies and resources for accelerating the shift to a more integrated, high performing and sustainable health care system. Speakers include Dr. Atul Gawande, distinguished surgeon, teacher and writer – named one of TIME magazine’s 100 most influential thinkers; Karl Rove, former Deputy Chief of Staff and Senior Advisor to President George W. Bush; and Donna Brazile, Al Gore campaign manager and Democratic National Committee Vice Chair.

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PRESIDENT’S MESSAGE Richard Podolin, MD

Gun Science, Safety, and Sanity Just over one hundred thousand people are victims of gun violence in America each year, not including those who are shot in police interventions.

Over thirty thousand people annually die from guns, including murder and suicide, and that number rises to over thirty-two thousand if unintentional killings are included. These deaths are not evenly distributed across the population. African Americans have twice the firearm related fatality rate of Caucasians. The disparity between states is even greater.

Over seventeen thousand American children and teens are shot each year, and nearly three thousand die. On average, eight children and teens die of gun violence every day. Annually, more children die of gun violence than cancer. Each year, the number of children under twenty years-old killed by guns in the United States exceeds the cumulative number of American military casualties in Afghanistan since the start of that war in 2001. Although San Francisco has a relatively low gun homicide rate per hundred thousand people (6.7), we compare unfavorably to New York (4), Portland (2.2), San Diego (2.8), Iraq (6.5), the Democratic Republic of the Congo (5.2), or Pakistan (4.5).

In 1993, the results of a study, supported by the Centers for Disease Control and Prevention (CDC), showing that gun ownership independently increased the risk of homicide in the home almost threefold were published in the New England Journal of Medicine. In response, the National Rifle Association campaigned for elimination of the center that funded the study, the National Center for Injury Prevention in the CDC. When that failed, Congress included the “Dickey Amendment,” in the 1996 Omnibus Consolidated Appropriations Bill, stating that “none of the funds made available for injury prevention and control at the Centers of Disease Control and Prevention may be used to advocate or promote gun control.” It is unclear what precisely is prohibited by this amendment, but no one has been willing to risk his or her career, or the agency’s funding, to find out. Since 1996, the CDC’s funding for firearm injury prevention has fallen ninety-six percent. In 2011, Congress added language similar to the Dickey Amendment to the legislation that funded the National Institutes of Health. In 2013, following the December 2012 mass shooting at Sandy Hook Elementary in Newtown, Connecticut, President Obama issued a Presidential Memorandum lifting the ban on CDC funding for gun violence research and “directing the CDC and other research agencies to conduct research into the causes and prevention of gun violence.” But Congress has continued to block funding, so young researchers are reluctant to pursue careers in this area and the field has languished.

A widely reported Florida “physician gag law” prohibits WWW.SFMS.ORG

physicians from asking patients about firearms in the home, or entering information about gun ownership into the medical record unless the physician has particularized information about the individual patient, such as suicidal or violent tendencies. The law was upheld by the 11th U.S. Circuit Court of Appeals over the objection of numerous physician groups who have argued that the law violates patient-physician First Amendment rights. A similar law (House Bill 2823) is now in committee in the Texas Legislature. It is less widely appreciated that Title X of the Affordable Care Act contains language inserted at the request of then Senate majority leader Harry Reid (D-NV) preventing the Department of Health and Human Services from collecting data on gun use, and stipulating that wellness programs can’t require a participant to give information about guns in the house.

Willful ignorance is an unacceptable response to any public health crisis. As physicians, regardless of our positions on gun control, we must defend the primacy of the patientphysician relationship, and we should be outraged by the political obstruction of scientific inquiry into a common and potentially preventable cause of death. Congressman Jay Dickey (R-AR), the sponsor of the “Dickey Amendment,” has publically and repeatedly expressed his regret for his role in stifling research on gun violence. He has pointed out that when highway deaths were studied starting in the 1970’s, the response was not to ban automobiles but to develop ways of making roadways and cars safer, saving an estimated 366,000 lives between 1975 and 2009. In an editorial in the Washington Post, Dickey related starting research on gun violence to planting a tree: “The best time to start was 20 years ago; the second-best time is now.”

Dr. Podolin is a cardiologist at St. Mary’s Medical Center where he has been chief of the medical staff and currently serves as vice-chair of the Community Board. He graduated from Stanford University School of Medicine, did his residency in internal medicine at the University of Chicago, and his cardiology fellowship at UCSF. Connect with Dr. Podolin via the SFMS LinkedIn Group or send him an email at podolin@sfms.org. For a full list of references, see www.sfms.org.

APRIL 2016 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

Diagnosing The Technological Imperative: Do No Harm “Western society has accepted as unquestionable a technological imperative that is quite as arbitrary as the most primitive taboo: not merely the duty to foster invention and constantly to create technological novelties, but equally the duty to surrender to these novelties unconditionally, just because they are offered, without respect to their human consequences.”

—Lewis Mumford , The Myth of the Machine, 1967 From the first time some bright ancestor of homo sapiens picked up a stick or rock to help fend off a predator, technology has seemed a very good thing. And so it has mostly been, other than the occasional aberration that gives us pause—a nuclear explosion, for example, which made even one of its primary inventors, J. Robert Oppenheimer, think twice about what he had helped bring about—but even that helped hasten the end of World War II. Medical technology is undoubtedly one of the most beneficial of all. In a broader historical sense, most of what we use in healing is relatively new. Other than a few surgical instruments, techniques, and non-surgical interventions only a century ago there was not much physicians had to offer but placebos, reassurances, and the intention and hope to “do no harm”. Some have even dated the advent of truly modern medicine as more recently to the discovery of penicillin by Fleming in 1928. Clearly there have been significant breakthroughs and improvements since then to countless patients’ benefit.

When it came to adoption of technology into work processes, health care delivery systems including physician medical groups were among the last groups to embrace the transition. In fact, there are still a significant percentage of practices that have not made the transition and some practitioners have opted early retirement and leaving medicine altogether to escape the inevitable move toward digital medicine. There was no question that the Internet was a great tool for clinicians, with references and resources at point of care in a smartphone app or iPad. Researchers also heavily used the Internet as a place to find references and access and add to databases available both nationally and internationally to facilitate and support medical research. But hesitancy came with concerns about cost of an unproven technology and on how computers might work in the actual clinical encounter that is at the core of the patient physician relationship.

In the relatively few short years that technology has entered the medical field, its footprint is now everywhere from its origins as a tool to support billing for services, to creating medical records, to storing laboratory results and confidential personal health information, to a communications tool for doctors and nurses to order lab tests and X-rays. Who would ever have imagined at the beginning that an entire history and physical or medical visit could be done electronically? With the rapid paced technological innovations in the field of digitizing communications and data, problems have arisen that demand caution, oversight, WWW.SFMS.ORG

and regulatory standards and enforcement including penalties for harm.

In this edition, the authors have reviewed some of the successes in management of chronic medical illnesses and working with diverse populations. The authors also raise the issues of 1) information accuracy and the need for validating tech devices that measure and record blood pressures and other vital signs or physiological measurements; 2) Information accuracy with medical records in the ER’s where the work flow makes it difficult to accurately record an encounter for staff taking care of multiple high acuity patients at the same time; 3) Information safety in maintaining confidentiality of patients’ personal health information; 4) Information safety from hackers who can hack into systems and encrypt the data from the health care system for profit; and 5) Information fraud or using the technology to report encounters for medical visits that don’t meet standards for reimbursement.

One remaining issue is who is responsible for oversight of this runaway train? Certainly any device or treatment used in the clinical practice of medicine needs FDA approval. But this jurisdiction does not extend to the actual physician or provider to patient encounter and the documents that are created, stored, and collated or researched. The Office of the National Coordinator does set some standards for the EHR (electronic health records) but they have not even addressed the use of social media and medicine. Certainly this is a dynamic and rapid changing field, so stay tuned for this and future editions on the digitizing of medicine.

Through all this change and innovation, we need to keep in mind that this is all about improving care, and we must not let technology distance us from patients. As Mumford, quoted above and one of the great thinkers of the past century, cautioned,”If we are to save technology itself from its present leaders and putative gods, we must in both our thinking and our action come back to the human center; for it is there that all significant transformations begin and terminate.”

Editor and cardiologist Dr. Fung is clinical professor of medicine at UCSF with a practice in consultative general clinical cardiology, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the nation’s first UCSF Asian Heart & Vascular Center located on the Mount Zion Campus. He is a former SFMS President. Steve Heilig is a staff member of the SFMS. APRIL 2016 SAN FRANCISCO MEDICINE

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Digital Health

THE FUTURE OF CARE Web-Based Comprehensive Disease Management Bertha L. Long, MPH, Michael Aratow, MD, FACEP, CMIO, David Pating, MD, FASAM Amidst the many changes in conventional healthcare, a quiet technological revolution is extending treatment beyond the doctor’s offices into the homes and lives of our patients. Leading this effort are

Bay Area startups like Ellipsis Health (EH), whose electronic web-based platform provides on-line treatment, wellness and prevention for chronic disease conditions. The developers at EH—a collaboration of experienced public health officers and health informatics experts—believe disease management does not reside within the traditional four walls of a hospital or clinic, but out in the community amidst the lifestyles of individuals.

These experts have designed smart personalized care management tools, which improve healthcare quality, patient experience, and overall population health outcomes at reduced cost.

Incorporating a modularized user-centered architecture, the EH platform flexibly bridges patients, providers, and health systems to support personalized care plans and provide continuous clinical monitoring and population management analytics. The EH platform allows clinicians to meet patients “where they are” with improved patient compliance and satisfaction. The platform includes behavioral self-management tools (e.g., automated messaging to patients for nutritional, fitness or medication goals for diabetes or weight management), peer-to-peer community support and real-time access to the care team (e.g., communications between patients and doctors, nurses, health coaches, nutritionists, fitness coaches, diabetes educators, case managers, etc.).

Patients and their families now can access their providers and meaningful health information that helps them adhere to their care plans and self-manage their health-related goals.

Unique to the EH platform are clinical workflows that are not covered by Electronic Medical Records (EMRs) but are still necessary in the transition from fee-for-service to a fee-for-value/results (and capitated) models. EH manages workflows that begin after the patient leaves the physician’s office. While the current generation of EMRs do have portals that permit patientprovider communication, they are based on traditional clinical encounters (clinic visits, ED visits, and hospital admissions) and not on population-based prevention nor personalized health maintenance strategies. EMRs were created as data entry vehicles to provide documentation for reimbursement and clinical encounters. Instead, the developers at EH believe the future for improved value-based care requires health systems to leverage patient data only accessible across multiple systems, including patient-informed goals tracking, hospital informed inpatient and ED visit indicators, and population-informed risk stratification—in other words, care management that occurs between clinical encounters.

All of this data allows clinicians and health systems to in10

tervene early to improve care and lower the healthcare costs of high-risk populations. These interventions include, for example, sending patients personalized care notifications to activate behavioral self-management plans following on-line progress monitoring or after unanticipated ED visits. Aggregating data from various sources including bi-directional clinical integration with various EMRs besides claims data also reduces cost by automating and consolidating chart data, as well as, data from labs and claims to generate and facilitate efficient submission of GPRO and HEDIS measures.

For the past several years in Riverside County’s Department of Ambulatory Care, the EH platform has been deployed to consolidate panel management for diabetics. A sample of seventy-six diabetic patients drawn from the County’s primarily low-income Hispanic population were significantly better engaged in the self-management of their diabetic care over a six-month period when enrolled on the EH platform. Their involvement in self-care management resulted in a statistically significant drop in their A1C. A paired t-test indicated that the mean A1C was significantly lower at six months (M=7.8, SD=2.1) compared to baseline (M=9.6, SD=2.7) [t(75)=7.49, p < 0.01, d=1.8]. With such dramatic improvements in mean A1C levels, Riverside County has now enrolled fifteen hundred patients on the EH platform.

One typical enrollee is Maria, an active patient at the Riverside Neighborhood Health Center, who is coached by Nancy Sewell, RDN. Maria registered in the Take Control of Your Diabetes (TCOYD) running event through a community post by clinic staff Gustavo Wong, RDN. By the time Maria had entered this event, she had already made tremendous progress with her clinical metrics. In just three months (August 25th to November 17th), she was able to achieve a weight drop from 237lbs to 219lbs (18lbs). Over the same period (August 13th to November 12th), her A1C levels dropped from 9.6 points to 5.9 points (a 3.7-point drop, or 39%). Maria celebrated her triumph by participating in the TCOYD event, and then sharing a picture of her celebrations with Nancy through the EH platform. As Xuanmai Nguyen, RDN notes, “Ellipsis Health has helped me stay better connected to my patients. My patients have been able to meet their self-management goals and improve their health outcomes. Patients love that they continue to stay connected with their healthcare team in between doctor visits.”

Continuing their commitment to the underserved and uninsured populations, the developers at EH have now directed their efforts to improving care for mental health and the social determinants of disease. Through the Behavioral Health Integration Initiative administered by the Inland Empire Health Plan, the EH

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Digital Health

SOCIAL MEDIA Bridging Disparities in Behavioral Health Kim Norman, MD The Center for Disease Control recognizes that sixty percent of health and wellness in America is attributable to social determinants such as poverty, education,

discrimination, early childhood development, and lack of access to health care. Another twenty percent results from health behaviors such as smoking, drug abuse and unprotected sex. Health care services, genes and biology account for the rest. (Source: Centers for Disease Control and Prevention www.cdc.gov/nchhstp/socialdeterminants/faq.html).

Social media holds the promise of placing social determinants at the center of patient care, rather than being checkmarks on the demographics page in their charts. Furthermore, healing is social, and natural language storytelling is the medium of doctorpatient interactions.

I created the Young Adult and Family Center (YAFC) at UCSF so that young people and their families can have access to care anytime, anywhere. We teach resiliency, inspire grit, and encourage young people to tell their own story their own way. We are dedicated to helping young people become their very finest selves, healthy in body, mind, and spirit, with a deep love of life and an abiding connection to others and the world around them. We create a place where lives transform and no one ever has to walk alone.

This is the vision statement of YAFC, and in order to fulfill its promise of care, anytime and anywhere, we are helping pioneer the use of social media to make quality, effective, behavioral health care available to everyone, not just the privileged few who make it through our doors. We use social media in a variety of ways. First, social media allows us to treat patients using videochats, text messaging, and social media-style postings. An abundance of studies has found virtual office visits as equal in effectiveness to in-person visits. Sometimes it is even better, as many patients prefer the safety and convenience of their own home, and tell us they are more open emotionally, feel their doctor is more present, and feel more equal and collaborative with their doctor online.

Social media makes true collaborative care possible. Multiple providers in multiple systems of care can literally get on the same

page in treating a shared patient. Family care givers, and other members of their support system such as nutritionists, teachers, coaches and social workers, can also join in the planning and delivery of care. Social media also makes it possible for families going thru a similar health crisis to guide and support one another.

Finally, social media allows the deployment of highly scalable therapeutic services, with the promise of eliminating health care disparities, by breaking down the barriers to accessing mental health care, including stigma, time and space logistics, dollar costs, and lack of availability of qualified clinicians.

Both of my sons are veterans of the Global War on Terror.

Inspired by their service, we have created a social media intervention in the form of psychoeducational courses. My sons came home from war. They got the help they needed. My promise to them is that anyone who has served, will be served!

Our Next Mission Project reaches active duty and veteran military service members at home and overseas. We offer a course on trauma, resiliency, and post-traumatic growth where participants can earn college credits or promotion points, thus overcoming stigma about seeking mental health services. We teach storytelling, as narrative is at the heart of all psychotherapies proven to be effective in trauma treatment. We also teach the neurobiology of stress and healing exercises such as mindfulness meditation and journaling.

Course content is presented in YouTube-style form, Ted Talkquality videos, homework assignments in the form of narrative writing, and facilitated online discussions. Protected Health Information is secured, as we use a HIPAA compliant social network.

Class discussions, student-to-student, and student-to-instructor communications can be entirely asynchronous. However, students are able to speak with instructors and each other in real time using instant messaging and videochat tools. The daily touch points provided by secure online discussions keep our students

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Social Media Continued from previous page . . .

The Future of Care Continued from page 10 . . .

engaged, thus producing higher completion rates than when we taught the course in person.

We have proof of concept. We are able to engage veteran and active duty service members who have never met each other, but share the common goal of healing from trauma, and sustain the engagement. They are willing to open up, bare their souls to one another, and inspire each other to do the work needed to heal.

Our outcomes are as good or better than in-person approaches at a fraction of the cost. Our students report reductions in post-traumatic stress symptoms, changes in tone from negative to positive emotions, and a return of optimism about their futures. As one soldier told us, “I got my laughter back.”

We have enrolled more than a hundred veteran and active duty service members to date. As we have gotten better at engaging and sustaining engagement by making our content interactive and our online discussions lively, our completion rates are now similar to in-person therapies. Our second course for Women Warriors is soon to be deployed, and with lessons learned, we expect even better engagement and outcomes. Because of our successes, we are now busy creating offerings for non-military trauma survivors.

We believe the success of our approach is because we place storytelling at the heart of our interventions. Medical practice is based on natural language storytelling. Symptom checklists, lifestyle-rating scales, and treatment compliance and response forms don’t tell stories, stories do. Listening to patient stories is how we learn how they are really doing, and by speaking with compassion, we provide comfort, inspire hope, and motivate change.

As we scale from hundreds to thousands of participants, we recognize the need and are now using powerful natural language analytics embedded in the HIPAA compliant social network we utilize. We use an application that helps us identify which personality traits, such as openness and conscientiousness, predict response to our interventions, and we will use these insights to improve our interventions. We also use an application that identifies cognitive and emotional themes that will help us better understand the mindset of trauma survivors, the risks their trauma presents to their health, and their progression through treatment. A third application measures emotional tone and enables us to assess responsiveness to our interventions and outcomes.

Social media returns storytelling to the practice of medicine.

It brings social determinants front and center while reducing social isolation. It has the promise of overcoming stigma and eliminating healthcare disparities, especially in behavioral health, while promoting behavioral change.

The time has come where we will no longer think of telemedicine, digital health, and social media as adjuncts or aids to medicine. We will just think of them as medicine.

platform targets adults with mild, moderate, and severe mental disorders, and substance abuse disorders with co-occurring physical health conditions at ten clinic sites within the Riverside County Health System to integrate behavioral health services into primary care settings. Using EH’s web and mobile chronic disease self-management platform, the behavioral health integration care team members (i.e., clinical psychologists, behavioral health integration care coordinators, primary care providers) engage patients to set and track goals via their computers, smart phones or feature phones. The platform not only assists patients and care teams with documenting, achieving and sustaining personalized goals around action plans, problem-solving and emotional management, but also enables the care team to pull lists of patients for targeted outreach and follow‐up based upon base-line statistics. The platform facilitates universal screening practices for mental health and substance use disorders via ongoing trainings, a HIPAA secure environment, end‐to‐ end encrypted communications and audit trails.

In the immediate future, EH plans to roll out visual and voice analytics modules that monitor emotional, cognitive and physiological states using externally visible and audible cues.

These modules allow call center clinicians to assess depression, imminent suicide risk, military PTSD and traumatized adolescents. Visual and speech bio-markers provide objective measures, which can be correlated with the speaker’s mental health status. All this not only improves healthcare outcomes, but also results in happier patients who are better understood by their health care team.

The Future of web-based chronic disease management is here. The only question is how fast systems can transition to these new systems while managing the many simultaneous demands of health reform. For now, comprehensively integrated disease management involving patient, provider and health system generated data holds deep promise for improving valuebased care.

Bertha L. Long, MPH, is at Loma Linda University, Riverside Family Care Centers. Michael Aratow, MD, FACEP, CMIO, is at San Mateo Medical Center. David Pating, MD, FASAM, is an addiction medicine specialist at Kaiser Permanente San Francisco. He is a longtime member of the SFMS and serves on the San Francisco Medicine editorial board.

Kim Norman, MD, is Clinical Professor of Psychiatry at UCSF and Director of the Young Adult and Family Center at UCSF. His research focus is on the creation of effective, scalable therapeutics for bridging disparities in behavioral health care. Dr. Norman has been selected to become UCSF’s first Distinguished Professor for Adolescent and Young Adult Health.

12

SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

Digital Health

EHRS IN THE ER As Doctors Adapt, Concerns Emerge About Medical Errors Shefali Luthra The mouse slips, and the emergency room (ER) doctor clicks on the wrong number, ordering a medication dosage that’s far too large. Elsewhere, in another

ER’s electronic health record, a patient’s name isn’t clearly displayed, so the nurse misses it and enters symptoms in the wrong person’s file.

These are easy mistakes to make. As ER doctors and nurses grapple with the transition to digitalized record systems, they seem to happen more frequently.

“There are new categories of patient safety errors” in emergency rooms that didn’t exist before the push to use electronic health record (EHR) systems, said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. Spurred by the 2009 stimulus package and the 2010 health reform law, the federal government has offered hospitals financial incentives to adopt electronic health records that, among other things, will add efficiency and reduce errors by linking physicians’ patient records and coordinating and tracking how care is delivered across the health system. Hospitals that don’t meet those standards are hit with penalties.

But in ERs, where things often happen fast, this push is sometimes setting up a technology mismatch that creates challenges that aren’t necessarily as evident in other parts of the hospital.

Sneaker-clad doctors and nurses rush between patients, often juggling multiple cases. Verbal communication is key. Patients, even after being wheeled in by paramedics, can wait in a triage room for extended periods until a free nurse or physician comes to find out what’s wrong. It’s a different style of medicine, and one that’s often resulted in a distinct workflow.

As a result, the electronic health record programs in many ERs evolved independently of hospital-wide systems. Since those homegrown, emergency department record systems often aren’t compatible with the newer, comprehensive ones hospitals are buying, they’re being phased out. The new EHR models are in many ways more efficient, but they may require adjustments.

“The way the systems are set up, it can actually predispose to higher error rates,” said Jesse Pines, who directs the Office for Clinical Practice Innovation at the George Washington University School of Medicine in Washington, D.C. In 2013, Pines, with other members of the American College of Emergency Physicians, wrote a report finding mistakes in the ER—like ordering the wrong medications or, because of confusing computer displays, more easily missing key patient information—were common after the switch to these digital systems.

“A growing body of evidence suggests that many errors may WWW.SFMS.ORG

be the result of poor design rather than user errors,” the report states. That “can have a profound influence” on patients.

“It’s certainly a patient safety concern,” said Jason Shapiro, an associate professor of emergency medicine at Mount Sinai, who chairs ACEP’s informatics committee and co-authored the report.

There’s no research measuring how often these errors— like entering care instructions in the wrong patient file or missing instructions altogether—cause actual harm.

“We’ve got to figure out how we’re working with our electronic records, to make it part of the workflow,” said Nathan Spell, chief quality officer at Emory Hospital in Atlanta. Even when doctors have learned to use the record systems, missteps still occur.

The ER’s culture and pace, for instance, can amplify the risks of human error that stem from an already less user-friendly system. Think of the emergency physician who, reaching the end of a hectic 12-hour shift, looks for the record of a patient he just examined. He types in the man’s last name, clicks and writes medical instructions—not realizing that he’d accidentally pulled up the file of another patient with the same last name and similar age, who was admitted five minutes before.

While misidentifying patients in this way was hardly an issue before EHRs, it’s “becoming quite prevalent” in this more digital era, Ratwani said.

Many systems, meanwhile, allow doctors to edit the record for only one patient at a time, said Zach Hettinger, who practices emergency medicine at MedStar Union Memorial Hospital in Baltimore. That makes it harder to keep track of things, he said.

“You’re stuck with, ‘Do I cancel what I’m in the middle of and not complete that task? Or do I deal with the new task? Do I make a note somewhere—take scrap paper—or just remember it?’” said Hettinger, who’s also the medical director for the National Center for Human Factors in Healthcare and has researched how electronic records work in the ER. How does that scenario play out? A triage nurse who is attending to multiple patients at once might scribble each individual’s details on the back of a piece of paper, ducking away later to enter the information into the computer system. That can make it easier to confuse things, and leave the emergency room short a nurse.

Computer systems need to better account for that potential human error, said Shawna Perry, an associate professor of emergency medicine at the University of Florida College of MedicineJacksonville, who has worked in multiple hospitals.

Stories of such near misses in the ER are now common lore, she added. In one episode, an electronic record system’s poor

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EHRs in the ER Continued from page 13 . . . design, which made the appropriate medication dosage difficult to read, led to an instruction for a nurse to give a child a sedative ten times the correct amount. The patient was fine, Perry said, but the incident demonstrates how a clunky or counterintuitive record can be dangerous.

“It was a simple slip of a cursor,” she said, questioning why the system even allowed the drug to be available in that strength for a forty-four-pound child. “How did this software fail its users?”

“That’s not an unusual event,” Perry added. “I know of many other situations. All of us do, by word of mouth.”

In fairness, electronic records have resolved many safety concerns, Pines said. They’ve rendered obsolete issues like misreading doctors’ handwriting. Accessing records is easier and faster, noted Dan Hampton, an emergency physician who works at Epic Systems, a major electronic health record vendor.

But because doctors don’t decide what a hospital buys, designs often emphasize what administrators or technology officials want, Pines said. To understand ERs, designers must spend time in them, Perry said.

“It’s one thing to have a computer and informaticists on your staff, or have a doctor come in and look at this [particular design feature],” said Robert Wachter, a patient safety expert and interim chair of the department of medicine at the University of California, San Francisco. “It doesn’t get into this issue of what does it look like to be using this system at four in the morning, when you have nine other patients and a trauma patient running into the ER, and your beeper’s going.”

Manufacturers said doctor feedback is important and something they prioritize in their designs.

For instance, Epic, based outside of Madison, Wisconsin, sends developers to hospitals to study their needs, Hampton said. “Making our software easy to use is one of our top priorities, along with quality of care and patient safety.”

At Cerner, another vendor from Kansas City, Missouri, doctors on advisory councils give feedback on the ER-specific system. Representatives visit emergency rooms to hear from physicians, said Leslie Lindsey, Cerner’s senior manager of emergency medicine.

But there’s room to improve, Lindsey added. To address oral communication, Cerner sells supplements, like a phone-like device meant to fix communication gaps with emergency medicine.

But hospitals may not want to buy add-ons when they’ve already paid tens or even hundreds of millions of dollars for a record system.

Despite these concerns, Pines said, it’s early. With time, companies will address kinks, so that patient safety issues diminish.

“Think about where we were even thirty years ago with cars. Cars are rapidly innovating to become safer and more efficient—and I think we can expect to see the same transformation in the electronic health record space,” Pines said. “Things are improving. And things will continue to improve.”

Shefali Luthra is a Kaiser Web reporting fellow. This article originally appeared on Kaiser Health Network, http://khn.org.

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Digital Health

DATA SECURITY The Dawn of Digital Medicine Tiffany I. Leung, MD, MPH, FACP Health information technologies promise increased patient access to health care, increased efficiency, and greater continuity of care delivery, as longitudinal

patient records are stored and accessible by authorized healthcare providers. As a millennial practicing in a telemedicinebased primary care practice, I routinely experience how technology-enabled care can be provided, and the vital roles that electronic health data and electronic communication systems have in supporting high-value patient and population health care. Health data streams are numerous and only growing, generated from electronic health records, social media streams and consumer engagement platforms, apps, and wearable and connected devices, including the internet of things. More data should allow for more informed decision-making, along with more intelligent clinical decision support systems and analytics that facilitate knowledge generation and discovery. Along with greater data diversity, health care delivery is increasingly distributed beyond traditional brick-and-mortar clinical settings, including telemedicine in the form of phone, video, secure messaging, and remote monitoring systemsâ&#x20AC;&#x201C;an industry rising towards an estimated thirteen billion dollar market.1 Amazingly, the full potential of health data and communication technologies to enable routine care access and delivery while also enabling secondary uses of the data for biomedical knowledge discovery, quality improvement, and clinical research is still to be fully achieved. As digital medicine innovations continue to grow, it is important for all clinicians to develop a general awareness of the security and safety issues regarding sensitive data and personal health information, now more than ever before.

Unauthorized access and breaches of data are occurring with greater frequency as healthcare relies increasingly on electronic systems for care delivery. The recent ransomware attack on Hollywood Presbyterian Medical Center, in which hackers accessed and encrypted health data and held for ransom the encryption key for nearly seventeen thousand dollars, is striking and worrisome. Since 2009, the HIPAA Breach Notification Rule mandates that breaches of data affecting five hundred or more individuals be reported within sixty days of the breach, and these reports are made publicly available via the Office for Civil Rights through the U.S. Department of Health and Human Services.2 Disturbingly, since reporting began in 2009, 1,487 breaches have been reported to date, affecting over one hundred fifty five million individuals, and the trends demonstrate that there is a steady and rapid rise in hacking and information technology-related incidents and unauthorized access (Figure 1), including breaches of network servers, e-mail, and devices like desktop and laptop computers.3 The internet of things (IoT), while not necessarily directly health-related yet, has also 16

received increasing attention for similar reasons; for example, recently, Nest thermostats and other IoT devices were suggested to have security vulnerabilities related to the devices and sensitive user data stored in the cloud.4 Fortunately, there are resources to arm ourselves as dayto-day care providers, with knowledge and awareness of these threats so we can better understand the language of data security. The Office of the National Coordinator for Health Information Technology provides an excellent primer and additional resources on the rules and regulations around health data security, beyond routine HIPAA training and attestations that are required annually of employees of large healthcare organizations.5,6 Just as the adage in medical education goes, it is also important to know when to ask for help on issues of data security.

As an employee in a large health care organization, addressing questions and concerns to a department of health information management or even risk management may be reasonable. Or, as a private practice, consulting with a malpractice or legal team that is knowledgeable in cybersecurity regulations could be informative as well.

While opportunities to revolutionize medicine with digital tools and increased electronic information carry these inherent risks, the rewards can be great. In primary care in particular, much of primary care practice involves care coordination and ensuring data cleanliness and integrity towards quality

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SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

Digital Health

TELEHEALTH What You Should Know Brittan Durham, MD Many terms—such as eHealth, telemedicine and telehealth—have been used to describe the use of communication technology in medicine. In this arti-

cle, I will use the term telehealth, defined as the use of telecommunication and information technologies in order for licensed medical care practitioners to provide clinical health care from a location that is distant from their patients. Telehealth is a tool used in the practice of medicine, not a separate form of medicine. The objective of this article is to highlight new developments in California telehealth law and review issues to consider when using this tool.

AB 415, also known as the Telehealth Advancement Act of 2011, was signed into law on January 1, 2012. This law changed the statute of California Business & Professional Code (BPC) section 2290.5 that governs telehealth services. The intent of this law was to integrate parity of telehealth into in-person traditional medicine.

The idea is that telehealth can provide health care delivery, diagnosis, consultation, treatment, transfer of medical data, care management and education using interactive audio, video and data communications in a real time (synchronous) interactive medium where the patient is at the originating site and the health care provider is at a distant site. Telehealth has been shown to be beneficial to patients living in isolated communities and remote regions where they receive telehealth care from physicians or specialists from far away. In addition, telehealth has been used by some hospitals to provide for rapid neurology consultation in patients with time sensitive treatment such as thrombolytics for acute cerebral accident (CVA).

According to BPC section 2290.5 (b), prior to the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient that telehealth may be used and obtain verbal or written consent from the patient for this use. The verbal or written consent shall be documented in the patient’s medical record. The consent should not alter the scope of practice or standard of care. Informed consent and privacy standards apply to all health care encounters including telehealth. A patient may receive in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services by telehealth.

While other states, such as Oregon, have instituted a new category of licensure for physicians practicing telehealth from an out-of-state location, California requires physicians providing telehealth services to patients located in California to have an active California medical license. There is a limited exception for out-of-state physicians if they are in consultation with a physician licensed in California pursuant to BPC section 2060.

Even under those circumstances, the out-of-state physician usWWW.SFMS.ORG

ing telehealth may not receive calls from patients, give orders, write prescriptions or have ultimate authority over patient care.

Under California law, a physician cannot prescribe medications (or recommend marijuana for medical purposes) without an appropriate prior examination and indications justifying the patient’s use of the drug. The Board has stated that this examination need not be in person, if the technology is sufficient to provide the same information to the physician as would be obtained if the exam had been performed face-to-face. A simple questionnaire without an appropriate prior evaluation may be a California practice violation.

The Medical Board of California (Board) has received complaints of inadequate medical examinations via telehealth. Undercover investigators posing as patients have revealed cases in which they were evaluated by Skype from a distant location.

Many of these evaluations had an inadequate history, no physical examination and resulted in no coherent treatment plan. Many of the associated medical records were inaccurate and some were fraudulent. A telehealth evaluation must meet the same standard of care as a face-to-face medical evaluation, consistent with use of the patient history, appropriate examination, and laboratory data, to arrive at a diagnosis and develop therapeutic plans. Medical record documentation requirements remain constant for all health care delivery modalities.

Out-of-state telehealth practitioners have been prosecuted.

The California State Appellate Court allowed California to criminally prosecute a Colorado-licensed physician for the unlicensed practice of medicine through telehealth. (Hageseth v. Super. Ct. of San Mateo Co. (2007) 150 Cal.App.4th 1399 (“Hageseth”). The patient in question, a California resident, obtained a prescription via telehealth after filling out an internet questionnaire.

No physical examination took place and the physician who prescribed the medication never entered California or had contact with the patient. With this case in mind, California physicians seeking to provide telehealth services to patients located in another state, while they (the physicians) remain physically in California, must ensure compliance with that other state’s licensing and telemedicine requirements.

There are no legal prohibitions to using telehealth technology in the practice of medicine in California, as long as the practice is done by a California-licensed physician, complies with BPC section 2290.5 and other applicable codes and regulations, and the care given meets the standard of care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers such as transmission of a patient’s medical information from an originating site to the health care provider at

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Telehealth Continued from previous page . . .

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a distant site without the presence of the patient.

This has been a brief administrative review of telehealth, which is evolving as I write this article. “Dial a Doctor” web interactive access is being marketed, diagnosis applications are available on smart phones, and digital medicine is poised to change the way patients can obtain and monitor their clinical data. For example, a home laboratory unit, which is literally a finger prick away from providing real-time data via smart phones, is already available. So stay tuned and connected, there is more to come.

California has been a major leader of medical technology innovations, and telehealth law will evolve to reflect future changes in the delivery of medical care. The Board will continue to monitor licensees to ensure the standard of care is met, which protects health care consumers by promoting responsible physician-patient relationships, regardless of technology used.

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Brittan Durham, MD, works on the Health Quality Investigative Unit, Tustin Office. This article was reprinted courtesy of Medical Board of California.

Data Security Continued from page 16 . . . measurement for preventive and chronic care services. Being able to provide care asynchronously and securely, using health information technologies to their fullest potential, would be supportive of routine care delivery. As a front-line provider, I partner with my patients to empower them with the tools and technology to be as healthy as possible. But my responsibilities as a clinician also mean that I must also be vigilant and aware of possible security threats, which can undermine the trust that patients place in their health care teams. Becoming familiar with the language of security and privacy is only a first but necessary step in the new world of digital medicine today.

Tiffany I. Leung, MD, MPH, FACP, is board certified in internal medicine and clinical informatics. She is Clinical Assistant Professor in Stanford’s Division of General Medical Disciplines. She currently practices at Stanford ClickWell Care, a telemedicine primary care clinic that promotes health and wellness using leading edge health technologies. A list of references is available at www.sfms.org.

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SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

Digital Health

BUYER BEWARE A Warning About Medical Apps Satish Misra, MD In a study presented recently at the American Heart Association Epidemiology and Prevention Lifestyle conference (AHA EPI) in Phoenix, researchers from Johns

Hopkins have shown one of the most popular medical apps to be inaccurate and misleading. Instant Blood Pressure became one of the most popular medical apps on the market soon after its release in 2014. The app claimed to measure blood pressure just by having the user put his or her finger over the camera and microphone over their chest.

At iMedicalApps, we came across this app nearly two years ago and wrote several articles highlighting the dubious, baseless claims being made by the app. Of particular concern was how people were using the app, outlined in reviews on the app store. That included a heart transplant patient touting its accuracy and a medic commenting on how easy it was to use.

Despite assurances from the developer that data to prove accuracy was on its way, no validation study or data ever materialized. The app remained in both the iTunes and Google Play app stores for nearly a year before being pulled first by Google then later by Apple.

In this study, Timothy Plante, MD, a fellow in General Internal Medicine at Johns Hopkins, led a team that tested the accuracy of this app in eighty-five participants in comparison with a validated blood pressure monitor used in major population health studies.

They reported this week that the Instant Blood Pressure app was off by 12.4 mm Hg for systolic blood pressure and 10.1 mm Hg for diastolic blood pressure. In patients with either low or high blood pressure, it consistently gave falsely normal values. And when it comes to detecting hypertension, the Instant Blood Pressure app had an abysmal twenty percent sensitivity.

And while most healthcare professionals could probably have guessed that such an app would be inaccurate, general consumers adopted it enthusiastically. During its life in the app stores, it was downloaded hundreds of thousands of time at a price ranging from $2 to $5, garnering exceptional ratings as well as rave reviews from users for its simplicity and accuracy.

While the low cost, scalability, and reach of medical apps confer much strength for their use in healthcare, this study highlights weaknesses and risks also created. This app slipped through the review processes of both Apple and Google, and it remained on the market for a really long time (as an aside, iMedicalApps editors did attempt to notify the appropriate parties about this app).

You might also assume that the Food and Drug Administration (FDA) or some other regulatory body may have taken issue with this app at some point. Devices that measure blood pressure are generally considered Class II medical devices. However, WWW.SFMS.ORG

as we’ve discussed in detail before, the FDA’s guidance on medical applications has carved out a very narrow subset of apps over which it intends to exercise regulatory authority.

In fact, with apps making dubious health claims, it has been the Federal Trade Commission that has been the most aggressive market policeman with fines, including recent action against Lumosity, which touted its brain-training games as a way to ward off cognitive decline.

Another next layer of defense, user reviews, clearly failed here as well, but that should not be surprising. Numerous studies of medical apps have shown that there is little relationship, if any, between user ratings and app quality.

In a study by Abroms et. al. showing the relationship between app store ranking and the app quality in smoking cessation apps; ranking and quality almost seem completely unrelated. This disconnect has been seen in other studies looking at apps for different health conditions as well.

Over the years, iMedicalApps has identified and called out apps that claim to treat acne with a smartphone’s light, measure pulse oximetry by putting a finger over the camera, and other apps that made specific health claims without evidence to back them up.

And those are just the most egregious examples, with many more apps and health devices falling into the gray area of implied health benefits paired with fine-print disclaimers that they are really just for entertainment or “general wellness.”

Overall, the study presented at AHA EPI highlights two very important points. First, there is no reason that we as healthcare professionals cannot undertake independent testing of medical apps and devices that make health claims without supporting evidence. Second, we need to educate consumers as well as clinicians on appropriate selection and use of medical apps in patients’ management of their own health.

Given the size and scope of the market, most apps will have little or no vetting, whether by some systematic certification process or third-party review like we provide at iMedicalApps.

In this marketplace, it’s “buyer beware”—and we need to help consumers understand of what things they should beware.

This article originally appeared in MedPage Today, http:// www.medpagetoday.com.

APRIL 2016 SAN FRANCISCO MEDICINE

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THE NEW CDC OPIOID-PRESCRIBING GUIDELINES The Centers for Disease Control and Prevention (CDC) issued guidelines in March that recommend primary care providers avoid prescribing opioid painkillers for patients with chronic pain. The risks from opioids greatly outweigh the benefits for most people, the CDC says. The summary points of the guidelines are:

1. Nonpharmacologic therapy and nonopioid pharmacologic

therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

2. Before starting opioid therapy for chronic pain, clinicians

should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks.

Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

3. Before starting and periodically during opioid therapy, cli-

nicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

4. When starting opioid therapy for chronic pain, clinicians

should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

5. When opioids are started, clinicians should prescribe the

lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to ≥90 MME per day.

6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

7. Clinicians should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work WWW.SFMS.ORG

with patients to taper opioids to lower dosages or to taper and discontinue opioids.

8. Before starting and periodically during continuation of opi-

oid therapy, clinicians should evaluate risk factors for opioidrelated harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use are present.

9. Clinicians should review the patient’s history of controlled

substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.

10. When prescribing opioids for chronic pain, clinicians

should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid-use disorder.

Issued March 2016; full 52-page document at: http://www.cdc.gov/drugoverdose/prescribing/resources. html

See Also

Checklist for prescribing opioids for chronic pain: http://stacks.cdc.gov/view/cdc/38025

JAMA Patient Information page: Opioids for Chronic Pain http://jama.jamanetwork.com/ article.aspx?articleid=2503507

CDC Fact Sheet/Checklist/Non-Opiate Tools: http://www.cdc.gov/drugoverdose/prescribing/resources. html

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SFMS ADVOCACY UPDATE John Maa, MD

Tobacco Control

Sugar Sweetened Beverage Legislation

On March 11, 2016, surrounded by tobacco control champions and lead author Supervisor Scott Wiener, Mayor Ed Lee signed into law Tobacco 21, which

Following the success of Prop D in Berkeley and the SFMS supported efforts with Prop E in San Francisco in 2014, a new effort to impose a penny-per-ounce fee to be paid

amends Health Code Sec.19H.14-1 and raises the minimum age to purchase tobacco products in San Francisco (including electronic cigarettes) from eighteen to twenty-one years of age.

Championed by public health experts, youth groups, and physicians, the SFMS-endorsed bill had passed through both the San Francisco Land Use committee and the full Board of Supervisors unanimously. The tobacco industry has stated their intent to file a legal challenge to the new law, citing pre-emption by State laws which they believe grant only the State the authority to regulate tobacco sales in this manner.

A 2015 Institute of Medicine study found that increasing the tobacco purchasing age from eighteen to twenty-one would decrease national smoking rates by twelve percent and reduce youth initiation of smoking by twenty-five percent. And, according to a study published in the American Journal of Public Health in 2014, cigarette sales to those under twenty-one account for only 2.12 percent of total sales. But, because ninety percent of smokers start by the age of twenty-one, these are the very sales that help lead to nine out of every ten new smokers.

Raising the minimum tobacco sales age to twenty-one will dramatically reduce tobacco use. A similar strategy was highly successful in addressing alcohol sales. A national age twentyone law for alcohol sales resulted in reduced alcohol consumption among youth, decreased alcohol dependence, and has led to dramatic reductions in drunk driving fatalities.

Just the day before, the California State Senate approved a similar bill that will raise the minimum age to purchase tobacco products to twenty-one across the State of California. Two important differences from the San Francisco bill are: members of the active military will be exempted, and the sales of electronic cigarettes may not be impacted as e-cigarettes are not yet defined as a tobacco product in California. The bill will arrive shortly on the Governor’s desk, along with a package of five other tobacco control bills that will restrict smoking in the workplace and schools, allow local jurisdictions to raise tobacco taxes, and also regulate electronic cigarettes in California. These efforts will provide momentum to the Save Lives California campaign—a coalition of CMA, SFMS, American Heart Association, American Lung Association, American Cancer Society, and public health advocates—which is nearing the completion of its signature-gathering phase in April to place a measure on the November 2016 ballot to raise the price of a pack of cigarettes by two dollars across California.

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by distributors on sodas and other sugar sweetened beverages with more than twenty-five calories per twelve ounces, with the proceeds directed towards the general fund, has moved into signature-gathering phase in San Francisco for the November 2016 ballot. Milk and naturally sweetened beverages without added sugars are excluded from this tax. The legislative champion is Supervisor Malia Cohen, who believes that the lower requirement of a simple majority to pass will be successful.

The benefits of the tax are three-fold: It 1) Creates awareness and helps educate the public about the link between sugary drinks and chronic illnesses, and how the beverage industry targets its marketing towards youth and communities of color; 2) Reduces sugary drink consumption; and 3) Revenues can be used to support community programs that combat the impact of sugary drink marketing, and the negative health consequences of sugary drink consumption.

The SFMS board of directors have unanimously voted to endorse the San Francisco Soda Tax ballot initiative. The evidence that demonstrates the correlation between sugar sweetened beverage consumption and increase in rates of obesity, diabetes, and heart disease is overwhelming. Visit http://www.sfms.org/forpatients/health-impacts-of-soda.aspx for more clinical research supporting regulation of sugar sweetened beverages.

A key event that will likely impact the public’s perception of the soda industry is the outcome of a lawsuit filed by the American Beverage Association against Supervisor Wiener’s 2015 bill to place a warning label on advertisements for sugar sweetened beverages on city property. The San Francisco Medical Society signed onto an amicus curiae brief in February 2016 submitted to federal court in support of Supervisor Wiener’s bill, and the matter moves forward in Federal court in April. A victory by the SF City Attorney in defense of Supervisor Wiener’s bill would represent the first major defeat in court for the soda industry, and may provide further momentum to the San Francisco soda tax as November 2016 approaches.

John Maa, MD, is a surgeon at Marin General Hospital, secretary of the SFMS, and a member of the San Francisco Medicine Editorial Board.

If you would like to join SFMS in our public health advocacy, please contact jkuo@sfms. org or (415) 561-0850 extension 268.

SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

SUPPORT FOR INCREASING CALIFORNIA’S TOBACCO TAX Kerin Arora, MD, Brian Goudy, MD, and Meredith Laguna, MD November 2016 is quickly approaching. On the bal-

lot this year are many propositions for which Californians will have an opportunity to cast their vote. One of the most pertinent propositions, particularly for the medical community, is the California Healthcare, Research, and Prevention Tobacco Tax Act of 2016. This bill will increase the tax on cigarettes by two dollars per pack. The proposition is supported by many influential organizations including The American Heart Association, The American Cancer Society Cancer Action Network, and The American Lung Association.

The two-dollar tax will only affect persons purchasing tobacco products. It is estimated that this bill will generate approximately $1.5 billion in its first year of enactment. The proceeds of the bill will go towards a variety of important causes.

Some of the most salient causes for the medical community include strengthening our health safety nets by ensuring additional funding to Medi-Cal, further funding for heart and lung disease research and tobacco related cancer research, and funding towards keeping youths and young adults tobacco free.

The Cost of Tobacco on California

Tobacco remains the leading cause of preventable death in California. Nearly 40,000 Californians die each year from diseases caused by tobacco. Treatment of smoking related disease cost the state over $13 billion dollars each year. The implementation of this proposed tax will result in significant healthcare dollar savings. More importantly, many lives will be saved

Our Significantly Outdated Tobacco Tax

California’s current tax on a pack of cigarettes is a mere 87 cents. As a state, we are ranked 33rd in the nation for tobacco tax rates. The last time California raised its tax was 1998. The national average for state tobacco tax is $1.54 per pack. New York taxes cigarettes at over $4 per pack; the tax in Texas is $1.41 and even Montana, Marlboro Country, taxes cigarettes at nearly twice California’s rate ($1.70). As a state, we are progressive and health conscious, it is time out tobacco taxation meets our state ideals.

Tobacco Tax Will Expand Access to Healthcare

California taxpayers pay over $3.5 billion dollars annually to treat Medi-Cal patients with tobacco related illnesses. This proposition will ensure that further funds go toward improving access to healthcare, including treatment of cancer, heart disease, stroke, lung disease and other tobacco related diseases for low-income Californians. Additionally, the tax will allot further funding to California medical residency programs thereby expanding the number of residency-trained physicians in the state.

WWW.SFMS.ORG

Expanding Tobacco Related Disease Research Revenue from this proposed taxation will be granted to The University of California to further fund life saving research for heart and lung disease and tobacco related cancers. Additional funds granted though this tax will keep the University of California on the forefront of cutting edge research. Research leading to better understanding of tobacco related disease pathology and treatment would ultimately lead to lives saved in California.

Youth Smoking Prevention

Increasing the costs of tobacco and tobacco related products are one of the most effective ways to reduce smoking among young people. A two-dollar increase per pack of cigarettes should be enough a deterrent to prevent many youths from buying their first pack of cigarettes. Tobacco addiction begins at the onset of use so this taxation alone will be an effective tobacco prevention and control strategy according to the 2000 U.S. Surgeon General’s report, Reducing Tobacco Use. In addition to cost as a deterrent to youth smoking, funds from this bill will go to the Comprehensive Tobacco Control Program, which has successfully aided in preventing smoking and use of other tobacco products through educational programs.

In its twenty-five years of existence, this program has saved the state of California over one billion dollars in tobacco related healthcare costs.

The Importance of Physician Support

Inherent to our profession as physicians is a desire to improve the lives of others. Because of this desire and aim, we have the trust of our patients. Our words and actions can influence our patients and communities at large. We have a responsibility to our patients and communities to help guide people toward healthier lives. Support of this bill will do just that.

Drs. Arora, Gaudy, and Laguna are pediatric residents at UCSF involved with advocacy efforts of SFMS.

References 1. American Lung Association, Why Kids Start. http://www.lung. org/stop-smoking/about-smoking/preventing smoking/why kids start.html.

2. Chaloupk FJ. Macro Social Influences: The Effects on Prices and Tobacco Control Polices on the Demand for Tobacco Products. Nicotine and Tobacco Research 1(Suppl 1):S1059, 1999.

3. The 2000 US Surgeon General’s Report. Reducing Tobacco Use. Centers for Disease Control and Prevention. http://www.cdc.gov/ tobacco/data_statistics/sgr/2000/complete_report/.

4. Save Lives California. http://www.savelivescalifornia.com.

APRIL 2016 SAN FRANCISCO MEDICINE

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Welcome New Members!

ACTIVE REGULAR MEMBERS Karen Ann Bockli, MD | Neonatal-Perinatal Medicine David Chou, MD | Psychiatry Tri Dang Do, MD, FACP, MPH | Internal Medicine Deborah A Gill, MD | Ophthalmology Brian Matthew Gilliss, MD | Anesthesiology Jonathan Lowentritt Kaplan, MD | Plastic Surgery Eun Min Kim, MD | Internal Medicine Zarine M Kotian, MD | Obstetrics and Gynecology Sarah Brigham Morocco, MD | Obstetrics and Gynecology Maureen R. Park, MD | Obstetrics and Gynecology Javier Raul Rangel, Jr., MD | Dermatology Steven Sheh, MD | Internal Medicine Andrew Wing Toy, MD | Physical Medicine and Rehabilitation STUDENTS David Corpman

SFMS Vaccination Public Service Announcement Featuring Musical Icon Graham Nash “Teach your children” is the title of rock legend Graham Nash’s most-loved song, and also of the new SFMS video wherein he urges parents to fully vaccinate their children. Mr. Nash, of “America’s Beatles” Crosby, Stills, Nash and Young, graciously offers his words and classic music for this 45-second public message, “I vaccinated my kids and they’re all brilliant!” he says.

Please enjoy and share this important message. See the video here: http://goo.gl/SKFd5D.

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CMA Leaders Advocate Physician Issues in Washington DC Elizabeth McNeil Nearly thirty physician leaders of the California Medical Association (CMA) traveled to Capitol Hill last week for the American Medical Association (AMA) National Advocacy Conference to lobby Congress about the associations’ top health care priorities. CMA physicians also met with the leadership of the Centers for Medicare and Medicaid Services (CMS), who are responsible for implementing the Medicare payment reform legislation (the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA) and the California geographic practice cost index (GPCI) “fix” that will overhaul California’s outdated geographic payment localities.

The group met with twenty-five members of Congress and forty staff members, lobbying for meaningful use simplification, Medicare recovery audit contractor audit reform, prescription drug cost reduction for patients, rational ways to curb the opioid epidemic, and the need to reverse the U.S. Department of Education’s regulation that excludes California physicians from the public service loan forgiveness program. CMA representatives also met with several CMS leaders, including Patrick Conway, MD, MSc, CMS chief medical officer and deputy administrator of the CMS Innovation Center. Dr. Conway is overseeing the implementation of MACRA’s alternative payment models. The group also met with the CMS staff responsible for implementing MACRA’s Merit-Based Incentive Payment System (MIPS).

The meeting with CMS was productive and encouraging. CMA leaders emphasized the need for CMS to simplify and reduce the administrative burdens in the meaningful use program and the Physician Quality Reporting System. Dr. Conway expressed a clear understanding of the problems physicians are experiencing with the current reporting programs. He told the group that he believes CMS will significantly improve those programs under the new MIPS regulations due out this spring.

CMA also urged CMS to open the pathway for multiple physician-led alternative payment models (APM). Dr. Conway noted that CMS is looking for a broad range of APMs to be submitted by physicians. The conversation led CMA to believe that APMs would not be limited to proven accountable care organizations that are accepting significant financial risk, as previously thought.

On the APMs, CMA urged CMS to provide physicians participating in APMs with total cost of care data for attributable patients to help them better manage their costs. Most importantly, CMA asked that any APM start-up costs and ongoing administrative costs be part of the downside financial risk calculations. Otherwise, only hospital-led systems would have the capital to participate. Dr. Conway clearly understood that individual physicians and small physician groups would not be able to accept the same level of risk, and encouraged CMA to continue to weigh in on these important issues.

CMA also reported that many national specialty organizations are aggressively developing APMs for submission to CMS. However, CMA told Dr. Conway that several specialties had reported that they could not meet the statutory requirements for APMs for various reasons, and the group pressed CMS to explore these barriers. CMA will remain vigilant and actively involved in MACRA implementation on behalf of California physicians.

SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

MEDICARE REIMBURSEMENT FOR ADVANCE CARE PLANNING Jeff Newman, MD and Steve Heilig, MPH

Talking with patients about their wishes for care towards the end of their lives takes knowledge, sensitivity—and time. Reimbursement for such Advance Care

Planning (ACP) was initially a casualty of the Congressional battle over the Affordable Care Act. Fear of putative “death panels” removed such payment in the final version. The following year, the SFMS and California Medical Association (CMA) asked the American Medical Association (AMA) to make re-instituting such payment codes a priority. As usual, policy change took some years—but our efforts have been successful. Physicians can now avail themselves of specific Centers for Medicare and Medicaid Services (CMS) codes for Medicare patients for The Conversation.

ACP provides patients (and their loved ones) the opportunity to anticipate and prepare for potential complications in their conditions. All Medicare beneficiaries deserve ACP to improve the quality and value of their medical care. Physicians should include prognosis and opportunities for prevention/treatment.

Clinical teams should encourage participation of family and partners, consideration of legal and spiritual counseling, and advice to complete Advance Directives. For patients with advanced illness and/or cognitive decline, Physician Orders for Life Sustaining Treatment (POLST) documents are recommended.

While these benefits are widely recognized by clinicians, the conversations are often difficult, and tend to become even more so when delayed. A focus on patient values and goals is likely to improve engagement and adherence to planning. Continuing interest in employment, hobbies, and family milestones may be

catalysts to think about and prepare for the future. Challenges may include need for caretaking and residence sustainability.

We urge primary physicians of Medicare beneficiaries to take advantage of the new reimbursement provided for ACP. While physicians need to initiate The Conversation, Physician Assistant, Advanced Practice Nurse/Nurse Practitioner, and social worker participation may also be charged.

A summary of the details for coding for clinicians and office managers is available at http://coalitionccc.org/2015/10/ advance-care-planning-codes-included-in-2016-physician-feeschedule.

In A nutshell

The two ACP codes are: • 99497 for an initial thirty minute voluntary advance care planning consultation (Final RVU 1.5) • 99498 as an add-on code for additional thirty-minute time blocks needed (Final RVU-1.4)

Our San Francisco Workgroup on Palliative Care is promoting education on ACP for the public and community organizations, to facilitate decision-making. There will be press coverage of the National Healthcare Decisions Day–April 16.

Online education for patients and families to facilitate ACP is available at https://www.prepareforyourcare.org.

March SFMS Physician Networking Mixer A Great Success Local physicians attended SFMS’ March Networking Mixer at Pa’ina in Japantown, where they had the opportunity to meet SFMS leaders, and connect with colleagues from a wide range of specialties and practice settings. SFMS President, Dr. Richard Podolin, briefly welcomed everyone and touched upon the medical society’s involvement in recent advocacy efforts with raising the legal tobacco purchasing age to 21 and endorsement of the San Francisco soda tax initiative.

SFMS would also like to acknowledge the Cooperative of American Physicians (CAP) for their support of SFMS and our joint networking mixer series. With great attendance and positive feedback from all, SFMS plans to organize similar social networking events throughout 2016. Please check the SFMS website or follow SFMS on Twitter (@SFMedSociety) for event details.

WWW.SFMS.ORG

APRIL 2016 SAN FRANCISCO MEDICINE

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RECEIVE MORE THAN $6,000 A YEAR IN SAVINGS AND SERVICES, INCLUDING: FOR $3 A DAY, SFMS/CMA MEMBERS

SFMS/CMA Member Benefit

Value

Patient referral service via SFMS’ phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $300 Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $110 One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . .*$150/hour reimbursement and practice operation issues . *value hourly rate with a practice management consultant Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Special member rate for AAPC’s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session Discounted registration for the Western Leadership Academy (eligible for 16 CME credits) . . . . . . . . . . . . . . . . . . . . . $300 CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $24 HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100 with other physicians at the point of care .

15% off tamper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . . . . $275 30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000 *based on average savings

Up to 25% discount on worker’s compensation insurance through Mercer Health & Benefits, as well as special . . . . . $750 pricing and/or enhanced coverage for life, disability, long term care, medical, dental and more .

Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $800 effective coding/billing strategies, and Medicare reporting compliance .

For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.

FEDERAL TASK FORCE TAKES MAJOR STEP TO UNITE CARE OF BODY AND MIND Sandra R. Hernández, MD The American health care system has just moved closer to a goal that I and many of my physician colleagues have long desired. Recognizing that depression is a

prevalent condition that’s inextricably linked to patient outcomes for physical diseases, the US Preventive Services Task Force on January 26 recommended that health care providers routinely screen patients eighteen and over, including expectant and new moms, for depression. For those who are working toward the vision of a highfunctioning health care system that assesses and treats the whole patient—both mind and body—this is a great moment.

Screening is a powerful tool. The Affordable Care Act (ACA) gives the task force recommendation the force of law, requiring health plans to waive copayments and deductibles for depression screenings. Millions of people with common, treatable behavioral health problems will be able to get the help they need.

This recommendation could not have come at a better time. The burden of untreated mental illness is a major public health problem that weighs heavily on our society; many people with mental illnesses do not receive the treatment they need. Several years ago, federal statistics showed that more than sixty percent of patients with any mental illness and forty percent of those with a serious mental illness did not receive any outpatient care, inpatient care, or medication treatment to address their condition. Mental health disorders are the leading cause of disability in the U.S. In 2014, nearly sixteen million Americans had at least one bout with serious depression, and about thirty thousand Americans die each year from suicide.

For the fifteen to twenty percent of women who suffer from depression during pregnancy or in the months after giving birth, the consequences of their mental health issues are significant. A mother with untreated postpartum depression is less likely to talk to, sing to, read to, or bond with her newborn, all of which can have a negative impact on her baby’s emotional and intellectual development.

If we are going to achieve the Triple Aim—better health, better care, and lower costs—we have to recognize that mental health and physical health are indivisible. Patients can’t maintain good physical health and practice wellness and healthful behaviors if they suffer from anxiety or depression. Likewise, patients with chronic physical diseases and conditions often have underlying mental health issues that make it harder for them to comply with needed treatments and behavior changes.

By treating the whole person, we can help a patient better manage chronic diseases and comply with the advice of his or her doctor. I have seen this repeatedly. Not long ago, a patient in my practice at the HIV clinic told me she stopped taking the antiretroviral medications that enable her to live a relatively normal life. This patient, who had always been good about taking her medication, gave a vague reason for her decision to stop the drugs. As I probed for details, she explained that she had been deprived of WWW.SFMS.ORG

sleep and depressed because her mother had been hospitalized after a stroke. Although her mother had been abusive, my patient was the only relative to visit her at the hospital. Her mother’s hospitalization had destabilized my patient. I unexpectedly found myself in a conversation with her over something that had nothing—and everything—to do with the course of her HIV. Finding out about the depression was as important to ensuring she got the care she needed as were her lipids or viral load. As a result of our conversation, I referred her for psychiatric care. She joined a peer-led grief support group, enabling her to express her complicated feelings without taking antidepressants. The situation reinforced the idea that if you are apathetic, hopeless, dark, and don’t eat or sleep, it doesn’t matter what treatments a physician offers or suggests for physical ailments—they will have limited impact. We can no longer dismiss patients as noncompliant without learning more about why. This is what patient-driven care management is all about.

Beyond identifying patients who need help and reducing the stigma of mental illness, screening will yield valuable data about the prevalence of behavioral illness, risk factors, and protective factors. It will also require that primary care physicians accelerate efforts to keep up with evidence-based treatment. If I learn from the data that thirty percent of my patients are clinically depressed, I’m going to want to become a lot more knowledgeable about managing depression. There are very real concerns that the task force’s screening recommendation could identify more behavioral health patients than existing resources can handle. New Jersey, currently the only state with mandatory screening for postpartum depression, had disappointing outcomes among women on Medicaid because of lack of continuity of care across providers and the lack of integration of mental health services and support into prenatal, postpartum, and pediatric care.

I believe the task force’s national standard will help to change that dynamic and lead to concrete steps to address workforce and other access challenges that are obstacles to care of depression. The new recommendation says screening should be implemented with adequate systems in place to ensure appropriate follow-up. Faced with increased demand, quality improvement programs will figure out how to better integrate care and thereby become more responsive to patients’ needs. We need to band together and make it a priority for payers and stakeholders to use all the available tools—the technology, diverse staff resources, and payer incentives—to make this succeed. Routine screening will strengthen the inner lives of patients and reduce the chances that any chronic health condition will progress into a life-threatening, acute episode because the patient is experiencing depression.

Sandra R. Hernández, MD, is president and chief executive officer of the California Health Care Foundation and a member of the SFMS. APRIL 2016 SAN FRANCISCO MEDICINE

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MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD, MBA

I’m excited to announce two new leaders at Dignity Health Saint Francis Memorial Hospital. Last month we welcomed a new hospital president, David Klein, MD, MBA, and earlier this year we announced Kathleen Jordan, MD, as the new chief medical officer.

Dr. Klein, a general surgeon, came to Saint Francis from Baylor Scott & White All Saints Medical Center in Fort Worth, Texas, where he served as president since 2013. With a strong reputation for dynamic planning, measurable organizational accomplishments, and mission-driven health care, his leadership will help guide us to meet the emerging health care needs of this city. He has had a proven track record of driving growth, physician relations, and quality care. He has overseen the construction and opening of new facilities, medical staff recruitment, successful implementation of Electronic Health Records systems, and fostered continuously high patient and employee satisfaction scores.

Dr. Klein joined Baylor in May of 2009 as the Chief Operating Officer and was named Interim President in 2012, and President in 2013. Prior to joining Baylor, Dr. Klein served as CEO of Cedar Park Regional Medical Center in Cedar Park, Texas, where his responsibilities included hospital quality and patient safety measures, medical staff and physician leadership development, and volume and revenue growth.

Dr. Jordan, who has served as Saint Francis’ primary infection disease consultant since 2010, will be overseeing the quality of care at the hospital as the new chief medical officer. She has worked in San Francisco as a private practitioner since 1998 providing infectious disease consultations.

Since her appointment, Dr. Jordan has been responding to the needs of our patients and medical staff. She also is working to engage new physician talent and keeping our medical services up to date in this everchanging health care environment.

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St. Mary’s

Robert Weber, MD

There is much good news to share from Dignity Health St. Mary’s Medical Center this month. For the third consecutive year, St. Mary’s received the Healthgrades Distinguished Hospital Award for Clinical Excellence™. This distinction places St. Mary’s among the top five percent of more than forty-five hundred hospitals nationwide for clinical performance as measured by Healthgrades. St. Mary’s also sits among the top three percent of hospitals who have earned this recognition three years in a row.

Orthopedics: St. Mary’s also recently received designation as a Blue Distinction® Center in Hip and Knee Replacement, part of the Blue Distinction Centers for Specialty Care program from Blue Shield of California. Blue Distinction Centers are nationally designated health care facilities shown to deliver improved patient safety and better health outcomes, based on objective measures that were developed with input from the medical community.

St. Mary’s Total Joint Center is renowned for its innovative approach to orthopedic services. In fact, our hospital was the first to perform a total hip replacement in California.

This designation highlights the high-level of orthopedic services our patients can expect when they come to St. Mary’s.

Women’s Health: Dignity Health recently commissioned a national survey exploring women’s (ages 40+) attitudes, behaviors and perceptions about mammography. The survey found—among other things—that more than half (fifty-three percent) of women who have not had a mammogram admitted they do not plan to have one in the near future.

Pamela Lewis, MD, medical director of the Sister Diane Grassilli Center for Women’s Health at St. Mary’s Medical Center, advocates for women to have an open and frank discussion with their doctor to help determine a roadmap for their mammography screenings, one that is personalized and tailored to their specific needs. St. Mary’s offers the most comprehensive breast imaging capabilities found in San Francisco.

SPMF

Bill Black, MD, PhD

At Sutter Pacific Medical Foundation (SPMF), our stroke telemedicine program has been received very well on many fronts. The program, based at California Pacific Medical Center and under the direction of stroke neurologist Dr. David Tong, has made it possible for thousands of potential stroke patients to receive expert diagnostic advice and a treatment plan from our trained team. By using one-on-one video consultation, we can recommend care for any patient presenting in the local emergency room of a participating hospital with a stroke or stroke-like symptoms.

Last year, the program won a Sutter Health award that celebrates innovative home-grown partnerships. This was a wonderful vote of confidence as the program was selected for the award by a vote of employees and affiliated physicians across the Sutter Health network. The program brings excellent and, in many cases, lifesaving care to thousands of patients, and it leverages a short supply of neurologists in the profession.

As a result of the award, the program received funding to expand its services. Approximately twenty hospitals in communities from the Oregon border to Visalia, California, participate in the program, and now there are several more hospitals that are able to take advantage of this valuable telemedicine service.

Because of its success, awareness of the program has increased and it has drawn interest from other specialties in SPMF. Specialties as diverse as cardiology, pediatrics, psychiatry, orthopedics and critical care medicine are investigating the potential of telemedicine services. Dr. Tong and his team are also exploring direct patient outreach into the home as well as the possibility of including other subspecialty areas of neurology.

The program has come a long way since it started in 2006, and we are fortunate to have the expertise and time commitment from these dedicated neurologists. It also shows how effective telemedicine can be at helping to deliver health care efficiently.

SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

MEDICAL COMMUNITY NEWS CMPC

Edward Eisler, MD

The California Pacific Medical Center (CPMC) Stroke Team and Davies Campus Staff completed a successful re-certification survey for Joint Commission Primary Stroke Center Certification. The surveyors were highly complementary of our commitment to high-quality stroke care for patients in our hospital as well as in our entire network of care.

Congratulations to Dr. Yuan-Da Fan, who has been reappointed as Chair of the Department of Obstetrics & Gynecology for a second term (2016-2020). Research lead by Sutter Pacific Medical Foundation’s Dr. Kidist K. Yimam, a hepatologist and medical director of CPMC’s Autoimmune Liver Disease Program, has been selected as a “Poster of Distinction” by the American Association for the Study of Liver Diseases to be presented during Digestive Disease Week held the week of May 21, 2016 in San Diego. Dr. Yimam’s research, done in collaboration with Dr. Christopher R. Kagay, chairman of CPMC’s Department of Radiology, and other clinician-scientists at UC Davis and the University of Calgary, illuminates a role for the assessment of liver stiffness measured by Magnetic Resonance Elastography in predicting liver failure and need for liver transplantation in patients with Primary Sclerosing Cholangitis.

A new approach to treating ovarian cancer provides similar benefits with less toxicity compared to a standard taxane-based chemotherapy dosing regimen, according to results published this month in The New England Journal of Medicine. The open-label, phase 3 randomized study was conducted by researchers at CPMC and leading cancer centers across the U.S., and suggests new strategies for personalized treatments. Encouraging clinical results from previous studies showed improved survival with a ‘dose dense’ administration of the chemotherapy drug paclitaxel, and increased progression-free survival (PFS) with the addition of the monoclonal antibody bevacizumab (Avastin®). The findings prompted lead study author Dr. John Chan, scientist and gynecologic oncologist at CPMC and colleagues, to determine if less frequent dosing of paclitaxel could provide the same PFS benefits.

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Kaiser

Maria Ansari, MD

The implementation of the Electronic Medical Record (EMR) at Kaiser Permanente, and the current focus on technology as a health care tool, has enabled our members to have greater access to their medical records.

In fact, many have come to expect it as a part of their health care experience. Since Kaiser Permanente began using the EMR, advances in technology have allowed more and more people to access the internet and communicate by using a mobile device of some kind, most commonly a smartphone or tablet.

We have made this process for members possible and easy by offering a host of tools that include free mobile apps, such as the flagship kp.org app and the NCAL Preventive Care App, which provides information about preventive care needs, cancer screenings, and immunizations. Additionally, members can easily book appointments online and access appointment information, whether it’s for an in-person office visit, telephone appointment, or video session. The apps also enable us to provide health tips to members during flu season and other seasonal events, such as allergies.

In creating a better physician/patient communication experience online, we have developed “My Doctor On Line,” which profiles all of our clinicians, provides information about their clinical practice and philosophy, as well as offering useful health information.

The webpages also help new Kaiser Permanente members view and choose a primary care provider. Through the use of online questionnaires, we are able to capture important information about new members and also monitor how current members are feeling, for example if they are showing signs of depression or weight loss.

Most recently, we have pioneered the use of video visits. Video visits provide the extra benefits of providing a personal touch to the virtual encounter, enables the clinician to make a visual assessment, and can also be used for consultation with a specialist remotely.

SFDPH

Alice Chen, MD

The San Francisco Health Network is the City’s only complete system of care, providing primary care, specialty, hospital, rehabilitation, skilled nursing, mental health and substance abuse services to San Francisco’s Medi-Cal and uninsured population. We also run the only trauma center and psychiatric emergency services for everyone in the City, at Zuckerberg San Francisco General Hospital and Trauma Center.

Operated by the Department of Public Health, the Network is deeply connected to the public health mission to protect and promote the health of all San Franciscans. Network staff and programs contribute to many citywide initiatives—tackling HIV, food insecurity, health disparities, homelessness, traffic safety and the hazards of cigarette smoking.

The Network’s patient population is made up of higher percentages of African Americans and Latinos than the City overall, and lower percentages of white and Asian people. Our patients face health disparities and challenges that we have expertise in treating. We are proud to offer them integrated primary and mental health services in our community clinics, top-rated birth services at Zuckerberg San Francisco General and fourstar rehabilitation and skilled nursing care at Laguna Honda Hospital.

Our goals are simple: improved patient experience, timely access to care and lower per capita costs. That is why we are investing in our primary care system, improving patient flow between our various levels of service, developing a universal electronic health record and creating models of care to meet the needs of our most vulnerable and highestutilizing patients.

Check out our progress on the San Francisco Performance Scorecard, which monitors how the City is doing in key policy areas: http://www.sfgov.org/scorecards

APRIL 2016 SAN FRANCISCO MEDICINE

29

MEDICAL COMMUNITY NEWS UCSF

Benjamin L. Franc, MD, MS, CPE

President Obama recently announced a new national initiative to eliminate cancer, backing it with a one billion dollar investment.

In February, Vice President Joe Biden visited UCSF to discuss this “Moonshot” initiative with top UCSF cancer experts. The visit included a tour of cancer research laboratories at the Mission Bay campus and a panel discussion led by Alan Ashworth, PhD, FRS, the Director of the UCSF Helen Diller Family Comprehensive Cancer Center.

Important upcoming events hosted by UCSF include the Bay Area Diabetes Summit, to be held March 13 at the Cole Hall Auditorium on the UCSF Parnassus campus.

UPCOMING EVENTS 4/13: SFMS Lobby Day/Legislative Leadership Conference | 9:00 p.m. to 3:00 p.m., Sheraton Grand Sacramento, 1230 J St., Sacramento | Join SFMS for the annual California Medical Association (CMA) Legislative Leadership Conference at the State Capitol. Learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands on experience in the practical aspects of physician advocacy. This one-day event includes education sessions on effective advocacy and lobbying techniques, briefings on legislative issues currently before Congress from CMA’s Government Relations team, and afternoon meetings at the Capitol with legislators and their staffs.

More than 400 physicians, medical students, and CMA Alliance members participated at the 2015 event. Event details at http:// www.sfms.org/events/lobby-day.aspx or contact SFMS at jkuo@ sfms.org or (415) 561-0850 x268.

4/20 Webinar: How to Reduce Overhead Expenses and Increase Profitability | 12:15 p.m. to 1:15 p.m., CMA

webinar | There are only three ways to realize increased net income: raise fees, increase productivity, or decrease overhead.

With managed care contracting difficulties, increased fees are difficult to achieve. The doctor/group may already be working at maximum capacity, so increased productivity may not be an option. This webinar will provide tips for physician practices to control and reduce overhead expenses to assure profitability. SFMS members receive complimentary access to this webinar ($99 for non-members) and can register at http://bit.ly/24VnfwE. 30

4/20: San Francisco Physician Investing Discussion Group Meeting | 6:00 p.m. to 7:30 p.m., First Republic Bank, 1088 Stockton Street | Ever wonder why Warren Buffet is so successful? Want to know how to choose equities, options and mutual funds? Interested in becoming a better investor for retirement or to supplement your income? Local physicians are starting up a new discussion group where doctors help doctors achieve their financial goals. Come join your colleagues for a stimulating evening. Novices to experienced investors are welcome! Light refreshments will be provided. For more information, please contact George Fouras, MD, at geofou@sbcglobal. net. San Francisco Physician Investing Discussion Group (SFPIDG) is not affiliated with the San Francisco Medical Society (SFMS).

SFMS has no responsibility for any of the information, advice, suggestions offered by any participant at any SFPIDG meeting.

5/4 Webinar: Contract Negotiations | 12:15 p.m. to 1:15 p.m., CMA webinar | When submitting a request to renegotiate a contract, best practice is to present a “business case” as to why the payor wants to keep your practice in the network.

However, many practices fail to present a business case, which often results in a quick reply from the payor indicating that they are not in a position to renegotiate at this time. This webinar will cover steps practices can take to build their best business case and identify the uniqueness of their practice to prevent the “auto-reply” and present a thoughtful renegotiation request. SFMS members receive complimentary access to this webinar ($99 for non-members) and can register at http://bit.ly/1SGIDkt.

5/13-15: Western Leadership Academy | Hilton San Francisco Union Square | Save the date for the 2016 Western Health Care Leadership Academy. Confirmed keynote speakers include renowned surgeon, writer and public health researcher, Atul Gawande, MD; Karl Rove, former Deputy Chief of Staff and Senior Advisor to President George W. Bush; and comedian, internist and founder of Turntable Health, ZDoggMD (also known as Zubin Damania, MD). The 2016 Leadership Academy continues its mission of providing information and tools needed to succeed in today’s rapidly changing health care environment.

The conference will examine the most significant challenges facing health care today and present proven models and innovative approaches to transform your organization’s care delivery and business practices. For more information, visit www.westernleadershipacademy.com.

6/4: Annual Summer Workshop in Clinical Ethics

8:30 a.m. to 4:30 p.m. | The Program in Medicine & Human Values at California Pacific Medical Center is organizing a skills workshop on resolving conflicts in the clinical setting as well as an update on common ethical issues encountered in patient care. The workshop is geared to bioethicists, physicians, nurses, legal counsel, risk managers, chaplains, social workers, administrators, ethics committee members, patient advocates, attorneys, security staff and interested others. CME and CEUs will be offered. For more information, please call (415) 600-1647 or visit www.cpmc.org/ethics/.

SAN FRANCISCO MEDICINE APRIL 2016 WWW.SFMS.ORG

The CMA/SFMS’s exclusive new Workers’ Compensation program can help your practice save money!

Savings

CMA members qualify for an additional 5% discount* on top of Preferred Insurance’s already competitive rates. Preferred’s rates are set for long term consistency, and are managed by focusing on safety and injury prevention, fraud prevention and the control of medical costs for your practice by getting employees back to work as soon as practical.

Service Mercer’s team of insurance advisors is knowledgeable about the needs of physicians and is available to walk you through the application process. Preferred’s claims examiners are experts in helping members with an employee injury or illness claim. Plus Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.

Safety In addition to mandatory CalOSHA information and videos on workplace safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this State.

Stability Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.

Call Mercer today at 800-842-3761 for a premium indication.

CMACounty.Insurance.service@mercer.com or www.CountyCMAMemberInsurance.com.

See how CMA/SFMS’s Workers’ Compensation team can help you save!

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*Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • Copyright 2016 Mercer LLC. All rights reserved. • 74455 (4/16) 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com

San Francisco Medical Society 1003A O’Reilly Ave. San Francisco, CA 94129 Return Service Requested

Find the best specialist for your patient with one call.

We make it easy to transfer and refer your patients to specialists at CPMC, part of the Sutter Health network. One call allows you to match your patients’ needs with the right specialist, notify admissions, get authorizations and more.

And we’re available 24/7, so you never have to wait to find the best possible care for your patients. It’s another way we plus you.

Referrals and Transfers 24/7 888-637-2762 cpmc.org