May 2013

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

Technology in Practice An Update for Users Physicians on Twitter: Giving Medicine a Stronger Voice

What Do Your Patients Find When They Google You?

Is Skype HIPAA Compliant?

Texting and Patient Confidentiality Selecting an EHR: Questions to Ask 2013 CMA Legislative Leadership Day

VOL. 86 NO. 4 May 2013

“ I have been very impressed by the personal attention MIEC has shown to my practice needs. They are always available to work proactively with me whenever a risk management situation arises.”

Dr. Paul Abramson Family Medicine - Insured by MIEC

Join the Insurance Company that always puts policyholders first.

MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For over 35 years, MIEC has been steadfast in our protection of California physicians. With Policyholder Dividend Ratio* conscientious Underwriting, excellent Claims 50% 47% management and hands-on Loss Prevention 39% 40% 36% services.

Added value: n No profit motive and low overhead For more information or to apply: n www.miec.com n n

Call 800.227.4527

29%

30% 20% 10% 0%

41%

30%

14% 2.2% 2007

6.4% 2008

5.2%

5.2% 2009

2010

6.9%

DISTRIBUTED

2011

8%

8%

2012

Med Mal Industry (PIAA Composite)

2013

MIEC

Email questions to underwriting@miec.com

* (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com

SFmedSoc_ad_03.28.13

MIEC Owned by the policyholders we protect.

IN THIS ISSUE

SAN FRANCISCO MEDICINE May 2013 Volume 86, Number 4

Technology in Practice: An Update for Users FEATURE ARTICLES

MONTHLY COLUMNS

12 Physician, Tweet Thyself: Social Media Gives You a

Stronger Voice

Kim Newell, MD

4

Membership Matters

6

Ask the SFMS

7

Classified Ad

7

Welcome New Members

8

Executive Memo Mary Lou Licwinko, JD, MHSA

14 Technology for Health: Do Mobile Health Technologies

Improve Health Outcomes?

Abby C. King, PhD

16 Barriers to New Technology: If It Works So Well, Why Aren’t

We All Using It?

Toni Brayer, MD 17 Your Online Presence: What Do Patients Find When

They Google You?

Debra Phairas and Ashley Porciuncula

18 Health Care Texting: Maintaining a HIPAA-Compliant

Environment

Andrew A. Brooks, MD

9

President’s Message Shannon Udovic-Constant, MD

11 Editorial

Gordon Fung, MD, PhD 32 Hospital News

20 A Secure Platform: DocBook Leads the Way in Secure

Health Care Communications

Tracy Haas, DO, MPH

OF INTEREST

21 E-mailing Patients: Does Your Office Have Written Guidelines?

29 2013 Legislative Leadership Day

22 Is Skype HIPAA Compliant? Video Conferences and

Patient Confidentiality

Rene Y. Quashie

34 Health Policy Superstar: In Tribute to

Philip R. Lee, MD

Steve Heilig, MPH

23 Selecting an EHR: Questions to Ask About Your Practice

and the Vendor

Kimbelee Snyder

28 Act Now to Avoid Medicare Penalties

25 Robotic Surgery in Gynecology: The da Vinci Surgical System

Leslie Kardos, MD 25 Favorite Apps for Physicians

27 Biomechanics: An Update from the St. Mary’s Lab

Jim Zucherman, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Physicians Advocate to Stop Medi-Cal Reimbursement Cuts at Legislative Leadership Day

to rate cuts as a budget solution.”

SB 640 would block the 10 percent Medi-Cal provider rate cut and would stop the state from “clawing back” rate cuts from providers dating back to 2011.

SFMS and CMA applaud Senator Lara for his commitment to ensure accessible health care for all. Cutting resources while adding patients to the Medi-Cal managed care system will make it hard for patients to find doctors and will delay much-needed federal health reform in California. The cuts in trailer bill AB 97 were proposed when California was facing an enormous budget deficit. Those times have changed, and there is no need to punish California’s poor and vulnerable patients any longer.

Update on Blue Cross Problems Affecting Accurate Payment of New Psychiatric Codes

CMA President Paul Phinney, MD More than 400 physicians, including SFMS members, participated in CMA’s Legislative Leadership Day on April 16 at the State Capitol. The SFMS group, represented by leadership as well as at-large members, met with Senator Leland Yee, Assemblymember Phil Ting, and legislative aides for Senator Mark Leno and Assemblymember Ammiano.

The group advocated heavily in support of SB 640 (see information below), the reinstatement of the CURES program, and against a handful of scope of practice bills introduced at this year’s legislative session. Photos and details from the event can be found on page 29.

SFMS would like to thank the participants for championing the cause of San Francisco physicians and their patients.

We hope to bring an even larger group to Sacramento for Legislative Leadership Day 2014.

SFMS/CMA-Sponsored SB 640 Bill to Stop Implementation of Medi-Cal Cuts Introduced

Senate Bill 640 was introduced by Senator Ricardo Lara (D-Long Beach) in April to stop the implementation of a 10 percent rate cut to Medi-Cal. The cut was part of the health services trailer bill (AB 97) to the 2011–12 state budget. SB 640 is cosponsored by the SFMS and CMA. “California has one of the lowest reimbursement rates for Medicaid in the nation,” said CMA President Paul Phinney, MD. “At a time when millions of new patients will be entering the program under health reform, the state should not be looking 4 5

San Francisco Medicine May 2013

SFMS/CMA received feedback from member psychiatrists with concerns about the way their claims were being processed by Blue Cross.

Following significant changes to the psychiatry category of the CPT manual, many practices reported that when they submitted a claim for an Evaluation and Management (E/M) code with a psychotherapy add-on code, the Blue Cross system was deducting two co-pays, one on the E/M and one on the add-on code. Additionally, physicians reported that they believed the pricing methodology Blue Cross used undervalued some of the new psychotherapy codes.

SFMS/CMA raised both concerns with Blue Cross in early March and learned that the system problem causing a double co-pay to be deducted was corrected on March 5. Blue Cross is in the process of automatically reprocessing the affected claims.

Blue Cross also notified affected physicians on April 12 of its decision to increase rates for several of the new psychotherapy codes, including CPT 90833, 90836, and 90838.

For psychiatrists who are on the standard Prudent Buyer fee schedule, Blue Cross has also increased pricing for E/M codes (99202-99205, 99212-99215, 99223, 99232-99233). The new pricing went into effect on March 13 and is retroactive to January 1. Blue Cross is in the process of reprocessing the affected claims.

Physicians with questions can contact Blue Cross Network Relations at (855) 238-0095 or networkrelations@wellpoint.com. SFMS members can also take advantage of the CMA reimbursement helpline at (888) 401-5911 to receive one-onone assistance on billing and reimbursement issues.

www.sfms.org

Support SFMS Members at 6/15 Prostate Cancer Run/Walk

May 2013

SFMS members Edward Collins, Robert Kahn, Ira Sharlip, Rodman Rogers, Stuart Rosenberg, and Lawrence Werboff of Golden Gate Urology will be hosting the Zero Prostate Cancer Run/Walk at Crissy Field on June 15, 2013.

The goal of the event is to help educate and create awareness about prostate cancer. The Zero Prostate Cancer Run is a premier men’s health event in the country and now has been held in thirty-two cities throughout the U.S. This is the first time the race will be held in San Francisco. For more information about the event, please visit zeroprostatecancerrun.

Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

org/sanfrancisco.

Volume 86, Number 4

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD

FAQs: Affordable Care Act Primary Care Rate Increase and Medi-Cal State Plan Amendment Under the provisions of the federal Affordable Care Act (ACA), MediCal is required to pay primary care physicians at Medicare rates for primary care services for two years. The increase is fully funded by the federal government. The requirement began January 1, 2013, and ends December 31, 2014.

The California Department of Health Care Services (DHCS) submitted its state plan amendment (SPA) to implement the rate increase on March 29, 2013. Approval of the SPA is required by the Centers for Medicare and Medicaid Services (CMS) before the state can implement the rate adjustment. It is unclear when the rate adjustment will be approved by CMS and implemented by DHCS. In previous communications, DHCS has indicated that it expects implementation will begin in July 2013. However, the rate adjustment will be retroactive to the beginning of the year.

SFMS has compiled a list of Q&As about implementation of the rate adjustment as outlined in the SPA on our website at http://bit.ly/17vMDvl.

5/16: Practice Manager Forum

Exclusively for medical practice managers. Enjoy a unique opportunity to meet local office managers, network with your peers, and share experiences at the SFMS Practice Manager Forum! SFMS is teaming up with the Northern California Medical Group Management Association to host a networking mixer for office managers and provide you with a support network, giving you a platform to share your information, ideas, and views on the smooth running of a medical practice. Visit http://event. pingg.com/SFManagers for event details and RSVP information, or contact SFMS at (415) 561-0850 or membership@sfms.org.

5/22: Reception for Assemblymember Richard Pan, MD

Join Drs. Andrew Calman, Roger Eng, George Fouras, Robert Margolin, Shannon Udovic-Constant, and other local physicians for an evening reception benefiting Assemblymember Richard Pan, MD. The event will be held at the SFMS office in the Presidio at 6:00 p.m. Visit http://www. sfms.org/Events.aspx for event details and RSVP information.

SFMS OFFICERS President Shannon Udovic-Constant, MD President-Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Immediate Past President Peter J. Curran, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Associate Executive Director for Public Health and Education Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Lauren Estrada BOARD OF DIRECTORS Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Keith E. Loring, MD Ryan Padrez, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD John Maa, MD Edward T. Melkun, MD Justin V. Morgan, MD Kimberly L. Newell, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

May 22: Documentation and Coding Auditing • 12:15 p.m. to 1:15 p.m.

May 29: Estate Planning after the Fiscal Cliff • 12:15 p.m. to 1:15 p.m.

June 5: Guide to Updating Your Partnership and Shareholder Agreements • 12:15 p.m. to 1:15 p.m. www.sfms.org

CMA Trustee: Shannon Udovic-Constant, MD AMA Delegate: H. Hugh Vincent, MD AMA Alternate: Robert J. Margolin, MD

May 2013 San Francisco Medicine

5

Get answers to your important practice-related questions with the help of SFMS experts. SFMS’s Ask the SFMS feature connects members with SFMS physicians and partners who can answer questions on a wide variety of topics dealing with the practice of medicine, ranging from practice management, patient education, and EHR assistance to health policy, legal/ malpractice, financial management, and more!

If you would like to submit a question to our experts, please e-mail info@sfms.org.

Affordable Care Act: Medicaid Primary Care Rate Increase; Medi-Cal State Plan Amendment (SPA)

Under the provisions of the federal Affordable Care Act (ACA), Medi-Cal is required to pay primary care physicians at Medicare rates for primary care services for two years. The increase is fully funded by the federal government. The requirement began January 1, 2013, and ends December 31, 2014.

The California Department of Health Care Services (DHCS) submitted its state plan amendment (SPA) to implement the rate increase on March 29, 2013. Approval of the SPA is required by the Centers for Medicare and Medicaid Services (CMS) before the state can implement the rate adjustment. It is unclear when the rate adjustment will be approved by the CMS and implemented by the DHCS. In previous communications, the DHCS has indicated that it expects implementation to begin in July 2013. However, the rate adjustment will be retroactive to the beginning of the year.

Included here are answers to frequently asked questions about implementation of the rate adjustment as outlined in the SPA. Please note that these provisions are subject to change pending approval by the federal CMS. 6 7

San Francisco Medicine May 2013

Why is the SPA just being filed now?

Federal guidance on the implementation of the rate increase was delayed until November 2012. The DHCS claims that the federal delay and the complications involved with applying the rate increase to managed care (see below) delayed the submission of the SPA.

Who qualifies as a “primary care physician”?

Any physician who is board certified in internal medicine, family medicine, or pediatrics by the American Board of Physician Specialties, the American Board of Medical Specialties, or the American Osteopathic Association. This includes recognized physician subspecialties of the above board-certified specialties.

Or, any physician who practices (but is not board certified) in a specialty or subspecialty of internal medicine, family medicine, or pediatrics who also bills at least 60 percent of services rendered for qualifying codes. DHCS has indicated that billing 60 percent of services for qualifying codes alone does not qualify a physician unless he or she also can legitimately attest to practicing in internal medicine; family medicine; pediatric medicine; or a subspecialty of internal medicine, family medicine, or pediatric medicine recognized by the ABMS, ABPS, or AOA.

How will physicians prove that they qualify?

Generally, physicians will self-attest that they qualify for the increased rates. The DHCS is developing an online registry that physicians will use to register. However, managed care plans are allowed to choose to either use the DHCS attestation tool or develop their own. www.sfms.org

What counts as a primary care service?

The rate increase applies to: • Evaluation and management codes 99201-99499 • Vaccine administration codes 90460, 90461, and 90471- 90474 • Preventive care codes 99381-99387 and 99391-99397 • Counseling risk/behavior intervention codes 99401, 99404, 99408-409, 99411, 99412, 99420, and 99429 • The rate increase also applies to state-specific “Z” codes— Z0100, Z0102, Z0104, Z0106, and Z0108. These codes are relevant to some state-only programs, such as Family PACT, as well as many services provided in neonatal and prenatal intensive care units (NICU and PICU). With CMA’s help, the state developed a “crosswalk” of codes that it provided to CMS to cover the Z codes.

Classified Ad Weight Management Practice for Sale San Francisco, CA. Medically supervised obesity treatment center. Staff includes PhD clinical psychologist, dietitians, physiologist, physicians, and nurse practitioners. All patients are physician referred. 2012 revenue $991,000.

Please respond to ml270g@gmail.com.

Welcome New Members

What Medicare rates will Medi-Cal use? Will they apply the GPCIs?

The SFMS would like to welcome the following members:

Per the SPA, rates will be based on the 2009 Medicare Fee Schedule. Geographic Payment Center Indices (GPCIs) will apply.

CMA urged the DHCS to adopt this approach based on our analysis that it would benefit California physicians.

Bonni Stacy Massa, MD Obstetrics and Gynecology

Are clinics or physician employers eligible for the Medi-Cal reimbursement adjustment?

No, only the physician who is personally providing the service is eligible for the increase.

Marvin Yuk-Ming Lo, MD Orthopaedic Surgery

Lauren Dana Standig, MD Internal Medicine

Does the increase apply to managed care?

Yes. Plans will be receiving increased payments, through the State of California, to pay providers at Medicare rates. The increase is fully funded by the federal government for two years beginning January 1, 2013, and ending December 31, 2014.

How will the state guarantee that the money actually makes it to the physician?

Plans will be contractually obligated to prove that they are paying primary care physicians at least the Medicare rates. The payments made to plans to cover the increased cost of higher rates will be separate from their general capitation payments, allowing for separate accounting. The SPA included plan reporting requirements to ensure that the rate adjustment funding goes to the service-providing physician.

Lishaun Francis is the associate director of medical and regulatory policy at the California Medical Association. Contact her at (916) 5512554 or lfrancis@cmanet.org.

SFMS and CMA members with Medi-Cal reimbursement questions can contact our Member Helpline for one-on-one assistance at (800) 786-4262.

www.sfms.org

Medical Review Officer Training (Special CME Programs)

Come learn the technical, legal and business procedures and guidance to act as a Medical Review Officer. This valuable certification and occupational medicine credential is required by some state drug testing laws and the U.S. Department of Transportation.

Comprehensive MRO Training Including Hair, Sweat, Oral Fluid, Alcohol Testing, and AAMRO Certification Exam San Francisco, CA June 21–23, 2013 (Friday–Sunday) Las Vegas December 6–8, 2013 (Friday–Sunday)

800-489-1839 www.aamro.com May 2013 San Francisco Medicine

7

EXECUTIVE MEMO Mary Lou Licwinko, JD, MHSA

Physician Payment Sunshine Act Beginning August 1, 2013, makers of drugs, devices, and biologicals covered by federal health care programs will be required to report payments and transfers of value that they make to physicians and teaching hospitals as part of the “Physician Payment Sunshine Act.” Over the years, I have heard mixed opinions from physicians about the value of drug companies and device manufacturers promoting their products through office visits, educational dinners, and physician-led forums. One physician in private practice confided that it had gotten to the point that she felt she could not even take a pen from a drug rep—which she felt was unfortunate, citing the value to a small practice of getting introduced to new drugs and being able to supply free samples to those who could not afford to pay for them. Other physicians and organizations have banned drug and device company-sponsored forums and reps from their offices, sharing the federal government’s belief that manufacturers may be exerting undue influence over physician choices. The American Medical Students Association reports that forty-four medical schools ban or restrict faculty from participating in drug company speakers’ bureaus. The Permanente Medical Group of Northern California banned these relationships years ago.

A recent article in the the Wall Street Journal indicated that some of the large pharmaceutical companies have severely cut spending on marketing to physicians through dinners and other forums. While some companies are already making available online data on payments they make to physicians, the Sunshine Act will require all companies to report this information annually to the federal government. Additionally, physicians or their family investment interests or ownership in manufacturing or group purchasing organizations also must be reported to the Centers for Medicare and Medicaid Services. The government plans to post the information on a public database beginning September 30, 2014.

The implementation of the Sunshine Act has caused concern across the health care field that it may stifle relationships that promote innovations. In “A Joint Statement on the 21stCentury Collaboration for Healthcare Advancement,” dated March 11, 2013, a coalition of physician organizations, medical centers, pharmaceutical companies, and device manufacturers laid out a framework of four principles it felt should guide financial relationships between doctors, scientists, and industry. They are:

The benefit of patients. Collaborations at any level, from the research lab to the doctor’s office, must aim to benefit patients and put patients’ interests first.

8 9

San Francisco Medicine May 2013

The autonomy of health care professionals.

Health care professionals and scientists must be free to independently assess multiple sources of information and treat each patient in a manner consistent with the patient’s needs and best medical practice. This is vital to preserve the public’s trust in the innovation process and in our health care system.

Transparency. Patients, and all those involved in health care, should have reasonable access to relevant and meaningful information about how academic institutions, researchers, health care professionals, and medical product companies engage in collaborative relationships. Transparency builds trust between patients and the health care professionals who serve them.

Accountability. All participants across health care must be responsible for their actions. External regulation is important here, but self-regulation with recurrent training and communication is essential to this effort.

As the act goes into effect, physicians will need to know how to report ownership or investment interests as required.

In addition, as some physicians have learned the hard way, the publishing of online data can be fraught with peril. Once the data is published it is difficult to retract or challenge its veracity, so doctors will need to be educated in how to challenge false or misleading information. In response to these needs, the American Medical Association is offering free webinars to members and nonmembers, along with information about the new law, key dates, and frequently asked questions on its Sunshine Act webpage. The California Medical Association and the San Francisco Medical Society will continue to provide guidance to their members as the act is implemented.

For information and advice on this topic from the AMA, see: http://www.ama-assn.org/ama/ pub/advocacy/topics/sunshine-act-and-physician-financialtransparency-reports.page.

www.sfms.org

PRESIDENT’S MESSAGE Shannon Udovic-Constant, MD

Women and Medical Leadership: More than Meets the Eye There has been a lot of commentary about President Obama’s recent comment about Kamala Harris being “the best-looking Attorney General in the country,” said during his visit to San Francisco to raise money for the Democratic National Committee.

This definitely hit a nerve with me. I recently watched Miss Representation, a documentary by Jennifer Siebel Newsom, that focused on the portrayal of women in the media with a segment on women politicians and how their looks, instead of their positions, were often the focus of the media. It doesn’t matter that it is nice of the President to say that Kamala Harris is good looking. As a woman in a position primarily held by men, the focus should be on her positions and the successes that she has had in this leadership position. President Obama should have known better. It is good that he apologized, but I hope that this helps to bring this issue to the forefront.

In Sheryl Sandberg’s best-selling book entitled Lean In, she talks about the “leadership ambition gap.” Despite the fact that women became half of college graduates in the United States in the 1980s, they are still underrepresented in leadership positions in America. Sandberg cites that only 21 of Fortune 500 CEOs are women, and that women hold 14 percent of executive officer positions, 17 percent of board seats, and are 18 percent of our elected congressional officials.

Part of the reason for this is that women purposefully scale back, especially in preparation for their role in family life.

This teaches institutions and mentors to invest more in men, because they are more likely to continue to climb into higher positions. Sandberg advised women to “not leave before you have left.” Recently I mentored a woman physician who was thinking about running for a position on a board that I am on.

She asked if anyone had gone out on maternity leave on that board before, because she thought it possible she might get pregnant during the term. I encouraged her to run and that it would get worked out, and that I would help to support her if this became an issue.

So how are we doing in organized medicine as far as women in leadership positions? At the San Francisco Medical Society, there have been 6 female presidents, including myself, out of the 145 total SFMS presidents since our inception in 1868. Dr. Roberta Fenlon was the first female SFMS president in 1960, and she also became CMA president in 1970. On the SFMS board we currently have 9 women (33 percent) out of a total of 27 board members. This is reflective of our membership, since we currently have 548 female medical society members (34 percent) out of a total of 1,594 members. The current CMA board of trustees has a total of 55 seats (including officers); only 13 are held by women and there are curwww.sfms.org

rently no women in the officer positions.

There are some systematic things that we can do in our profession to support gender equality. In Sandberg’s book she tells the story of an attending physician at John’s Hopkins who said that after listening to Sandberg’s TED talk entitled, “Why We Have Too Few Women Leaders,” when she talked about the fact that fewer women raise their hands when a question is asked, he stopped asking for hands to be raised and instead started calling equally on male and female students and found that the females knew the answers just as often. We can do this when we are teaching students and residents. But also, when we are leading board discussions, we can ask for input from members who might not raise their hands yet could provide valuable input in the discussion. In Lean In, Sandberg states that the “simple act of talking openly about behavioral patterns makes the subconscious conscious.”

I am approaching this in a few different ways. One, teaching my children, a son and a daughter, that all opportunities are open to both of them. Second, seeking out qualified women and other underrepresented physicians who are interested in leadership opportunities within organized medicine. Finally, looking at ways that we can support family-friendly policies within the medical society so that both men and women who are interested in being involved don’t have to choose between family and leadership.

When my daughter was four years old, we took the money that she had been given as birthday gifts to open a savings account for her. She looked at the bills with male Presidents on them and asked, “How come I only have boy money?” I hope that someday she will see the faces of women leaders all around her. As Marian Wright Edelman, of the Children’s Defense Fund stated “You can’t be what you can’t see.”

May 2013 San Francisco Medicine

9

Are you thinking about an EHR? Have you implemented an EHR?

What’s

next?

Whether you are working towards meaningful use, CMS’s PQRS*, or any other quality initiative, Lumetra Healthcare Solutions can help you harness technology to increase efficiencies, qualify for incentive payments and improve the quality of patient care.

Lumetra Healthcare Solutions is an industry leader in EHR optimization, offering a full range of clinical, technological, and analytic services. Whatever EHR system you have in place, our professionals will partner with your practice to:

^ Improve care management, quality and safety through practice

Practice Assessment EHR Selection Workflow Security eRX

transformation.

^ Adopt a systems-based approach to continuous quality improvement. ^ Meet changing reimbursement and delivery models.

Registries Patient Engagement

^ Access high-quality data.

We offer a variety of service package options.

Contact us to discuss an option that best meets the needs of your practice.

Analytics & Repor ting Meaningful Use

*Centers for Medicare & Medicaid Services’ Physician Quality Reporting System

One Sansome Street, Suite 950 San Francisco, CA 94104 Phone: 415-677-2137 E-mail: info@lumetrasolutions.com 11

San Francisco Medicine May 2013

www.sfms.org

EDITORIAL Gordon Fung, MD, PhD

Technology in Health Care Technology and health care have a love-hate relationship. There is a growing use of technology in education: We upgrade anatomy laboratories and share lab dissections of a cadaver with the class; we stream and record lectures to allow students to hear from world experts in real time or later, at the learner’s convenience.

High-fidelity recordings of the heart, with scientifically proven instructions for hearing specific murmurs and heart tones, are magnified 400 to 500 times so we can best memorize those sounds to aid in future diagnoses. Simulators teach cardiopulmonary resuscitation and other procedural skills needed for surgery and advanced procedures.

In diagnostics, we have advanced evaluations, including CT scans; MRI; genetic testing; special immunologic testing; and biopsies directed by X-ray, ultrasound, or robot. Umpteenthgeneration scanners reveal parts of the vascular lining that were never before seen and help demonstrate how some diseases progress. We can acquire, store, and transmit data so that physicians don’t even need to be physically present to make some diagnoses (as was discussed in last month’s article on telemedicine).

In treatment, we’ve developed laparoscopic surgeries, turning large, high-risk surgeries into percutaneous procedures. Witness the new TAVR (transcatheter aortic valve replacement), percutaneous coronary interventions (PCI), and stents, replacing open-heart coronary artery bypass grafting (CABG) and intracranial laser surgeries.

These technologies represent the “love” half of the lovehate relationship. So where is the “hate”? It lies in the concern that increased dependency on technology means decreased dependency on good history taking and physical examinations skills. Take the situation of a patient presenting with chest pain to the emergency department. There is such dependence on technology that the first step is an ECG with laboratory tests to exclude an acute coronary syndrome. Next comes the HD (highdefinition) CT scan to exclude an aortic dissection or pulmonary embolus. If the patient presents for an evaluation of any problem and is found to have a heart murmur, the physician orders an echocardiogram rather than spending the time to listen and reflect on the actual heart murmur to determine whether it is benign.

In teaching, the dependence on technology makes it harder for schools to plan physical space for classrooms—better to replace them with a television studio that can automatically stream to different sites throughout the campus or to dorm rooms. Group lectures may become dinosaurs.

Thus the use of technology in diagnosis and treatment has become a love-hate issue in health care, and the balance is different among different stakeholders. Physician providers love the use of new technologies to provide better images and genetic markers. Payors believe the technology is too expensive www.sfms.org

unless the benefits are scientifically proven. For treatment, we are still learning the best and safest uses of these new technologies.

But this month’s theme, technology in practice, covers the next step, one that will only exacerbate the ambiguous relationship between technology and medicine. Physicians have always known that patients talk to each other about their physicians and hospitals. But the newer social media, with rating scales putting every provider on Yelp or Craigslist or Google, goes further than anyone imagined. Some providers have been raved about, which doesn’t bother anyone; others have been badly maligned without any possibility of explaining what really happened or whether the comments were even accurate. Newly developed websites may help, but, unfortunately, once someone posts something on the Web it can be there forever. So we need to read about this phenomenon, as discussed in the article by Debra Phairas and Ashley Porciuncula.

Toni Brayer and Kim Newell discuss the use of social media in a medical practice. Most physicians are concerned about complying with the numerous regulations that govern practice, especially HIPAA. So the articles by Tracy Haas and Renee Quashie are important to read.

One of the hottest topics at most water fountains in hospitals is the transition to the electronic medical or health record (EMR or EHR). Every member of the health care community is trying to comply—some have already adopted it, some have yet to jump in, and some have strongly considered retiring early so they don’t have to make the conversion. Whether such conversion marks a significant change in the quality of outcomes remains to be seen; the one thing we do know is that during these expensive conversions, there is a reliable loss in productivity and an increase in expenditure to support the transition.

And finally, a big question: Do mobile health technologies improve health outcomes? Software engineers all over the world are trying to develop health apps that can monitor and track patients’ every measurable function and vital sign.

Do physicians even know how to interpret this information?

And does it help patients become more involved in their own health? Please read Abby King’s article for a thoughtful discussion of these issues.

I recently went to a conference on the future of medicine.

The keynote speaker said that the most significant breakthrough is the development of a mobile app that will change human behavior. We’ll all have to stay tuned to see if that turns out to be a reality!

May 2013 San Francisco Medicine

11

Technology in Practice

Physician, Tweet Thyself Social Media Gives You a Stronger Voice Kim Newell, MD I can’t tell you how many times patients come into my office and say, “Dr. Newell, I’m worried about my son’s

green poop” (or some other common concern), and I reply, “It looks odd and scary, doesn’t it; however, it’s very normal. Infant stools become green when the stool transits a bit more rapidly through the intestines” (or some other empathetic, authoritative, evidence-based answer). They say, “That’s exactly what I read on the Internet, but I needed to hear you say it.”

And then there are the parents who have “done their research online” and are quite confident that vaccines are harmful to their children, and so they would like to avoid giving them to their children altogether and are completely closed to my earnest and scientific reassurances about vaccine safety.

Or the patients who arrive at my office with a diagnosis and treatment plan for a problem that, it turns out, they don’t actually have, although their diligent online conversations convinced them that they did.

Our patients are getting overloaded with health information from more and more sources, and yet they often don’t get to the right answer. And recent studies have shown that more than 98 percent of the online health-related discussions take place without the input of a health care professional.

How do we make sure that we remain an integral part of our patient’s health care conversations? As a pediatrician in an increasingly complex health care delivery system, in which I must provide more care with higher levels of service to increasingly savvy patients in less time, I have begun to turn to technology, the Internet, and especially social media to help me do my job better.

What is social media? Broadly defined as digital channels that can facilitate timely, collaborative, and interactive communication, it includes venues such as Twitter and Facebook, YouTube and blogs.

The statistics are mind-boggling: Facebook has more than 1 billion users swapping photos, sharing articles or books or quotes, celebrating their teams, and bemoaning their illnesses. According to a recent study, 85 percent of users log onto their Facebook account every single day.

Twitter has more than 500 million users who broadcast news, share links to interesting articles, and converse about topics from the weather to politics to disease outbreaks.

Who are these users? They are our patients. They are 12 13

San Francisco Medicine May 2013

journalists. They are health care policy makers. They are pharmaceutical companies, insurance companies, and hospitals.

The encouraging news is that though physicians have been slower than some to engage, a recent study showed that 25 percent of physicians use social media daily as an information source.

I began my own process of learning how social media can become integral to my practice as a physician about four years ago. I am a sometimes blogger at drkimmd.com, I tweet actively (my twitter handle is @drkimmd), and I’ve also been a part of a pilot project with the Permanente Medical Group’s first foray into physician tweeting (@kpbabydoctor).

There are many compelling reasons that I am active in social media.

Social media makes me more efficient. I save time (and my voice) by sending my patients to my website to learn about why their child has green poop or how to tame their diaper rash.

Social media strengthens my connection with my patients. As I write about my joys and foibles in parenting, I become more human, which actually increases my authority with patients.

Social media keeps me up to date. Twitter is now my primary source for news about pediatrics, parenting, and health care policy. Twitter is an information accelerator, and there I get health news hot off the press. It has become the most efficient way for me to keep up both with scientific literature and with the popular media’s take on health news (which my patients are reading).

Social media helps me network. Twitter has allowed me to interact with peers and colleagues in ways not previously possible: Just today I conversed with new contacts in three different states about an infant’s undiagnosed GI issue, and then watched a fascinating webcast about social media and health care put on by my own organization that I learned about on Twitter. Through Twitter I have also been asked to write a forward to a parenting book and advise a start-up company on a new mobile health product.

Social media gives me a voice in the sea of health information. Through my blog and Twitter I give scientific, evidence-based, timely, and practical guidance on child health and parenting. Without physicians involved, this discussion can be unbalanced. When Jenny McCarthy claims that vacwww.sfms.org

Dr. Kim Newell is a general pediatrician at Kaiser Permanente and a member of the SFMS board of directors. She studied comparative religion at Princeton University before attending medical school at the University of Pennsylvania. She began to learn about technology and medicine upon moving to San Francisco for residency at UCSF and is now a technology lead at Kaiser, where she also teaches a class about vaccine safety for parents and helps lead an innovative obesity management program. She tweets at @drkimmd and sometimes blogs at drkimmd.com.

cines are unhealthy for our children on the Oprah Winfrey show and Donald Trump chimes in to agree, we have to get involved in the conversation—otherwise, the conversation is dominated by tweets about the “dangers” of vaccines.

There was a time when we physicians didn’t have to compete for our patients’ attention—we were the one voice in the room. I believe that the core of our healing still happens one on one, with patients in our examining rooms. However, we must also begin to meet our patients where they are: on their smartphones and tablets and computers, doing research and engaging in discussions on Twitter and Facebook and in the blogosphere.

There’s a conversation going on. About health.

If you’re not active in social media, your voice as a physician, a scientist, a healer, and an advocate is likely to be drowned out.

In the end, the key is not in the technology or the tweets: It is in the trust that we build with patients. We, as a medical community, must figure out how to be not only a part of the health-related conversations happening in social media but also to lead those discussions. We can and must use these channels to combat misinformation, promote health, and engage the trust of our patients.

radiology practice, a leaking fire suppression system destroyed a $1,000,000 1.5 tesla MRI. Make sure you’re covered.

In a Los Angeles

For decades, The Doctors Company has provided the highest-quality medical malpractice insurance. Now, the professionals of The Doctors Company Insurance Services offer the expertise to protect your practice from risks beyond malpractice. From slips and falls to emerging threats in cyber security—and everything in between. We seek out all the best coverage at the most competitive prices. So talk to us today and see how helpful our experts can be in preparing your practice for the risks it faces right now—and those that may be right around the corner.

Call (800) 852-8872 today for a quote or a complimentary insurance assessment. n n n

Medical Malpractice Workers’ Compensation Health and Disability

CA License #0677182

4362_SFranciscoMed_May2013.indd 1

www.sfms.org

n n n

Property and General Liability Employment Practices Liability Directors and Officers/Management Liability

n n

Errors and Omissions Liability Billing Errors and Omissions Liability

www.thedoctors.com/TDCIS

4/1/13 11:51 AM

May 2013 San Francisco Medicine

13

Technology in Practice

Technology for health Do Mobile Health Technologies Improve Health Outcomes?

Abby C. King, PhD Mrs. Hernandez had struggled with her weight for a long time, despite warnings from her primary care pro-

vider and the admonishments of one of her adult daughters, who feared that she would succumb to the type II diabetes that had plagued the family over several generations. While she understood the general importance to her health of engaging in more physical activity, she felt overwhelmed at the thought of trying to find time to exercise within a busy schedule. It was easy for physical activity to take a backseat to what she perceived as more urgent and higher-priority daily duties and obligations.

At the urging of a friend, Mrs. Hernandez signed up for a pilot study at Stanford Medical School, testing different mobile phone applications (“apps”) for promoting more physical activity and less sitting throughout the day. The study was aimed specifically at adults who had never used either smartphones or mobile phone apps. While initially skeptical about the usefulness of such programs, she was surprised to find her daily physical activity levels increasing over a twomonth period. This success, in combination with subsequent changes in her diet, resulted in a 20-pound weight loss.

In joining the study, Mrs. Hernandez joined the billions of people worldwide using communication technology to improve their daily lives in a number of arenas, including health.

The explosion of cell phone use across every strata of society within virtually every nation in the world has opened up unparalleled avenues for reaching people with personalized and timely information in a manner often more convenient for both the patient and the provider.

Health Behaviors: A Prime Target for Mobile Health (mHealth) Programming

Arguably, nowhere is the promise of mHealth greater than in the behavioral health field. A significant proportion of deaths in the U.S. and globally have among their root causes three major health behaviors—tobacco use, physical inactivity, and unhealthful diets. Yet programs aimed at improving these complex health behaviors have often occurred outside of clinical settings entirely, or with clinical and community organizations sharing the load, often with inconsistent or short-lived results. Given this situation, health professionals have increasingly recognized the need for information technologies that can bridge location, time, and cost barriers in delivering personalized advice and support in a consistent and trusted fashion.

14 15

San Francisco Medicine May 2013

The Promise and Challenges of Using Health IT in the Behavioral Health Field Over the past several decades, a growing scientific evidence base has demonstrated that behavioral health programs delivered through a range of communication channels—among them telephone and tailored print communications—can promote sustained behavior change across periods lasting two years or more. What is currently less well known is how well the behavioral principles and strategies underlying such successful programs can be effectively transferred to automated systems. A major challenge concerns how best to promote sustained patient engagement over time after the novelty of automated communication wears off. A good example of this conundrum is reflected in the use of health websites. While many such Web-based programs have shown short-term behavioral success, sustaining patient interest and engagement with websites over time has often proved challenging. With the advent of social media (e.g., Facebook, Twitter), Web-based programs and similar technologies can be enhanced or, potentially, replaced. However, systematic evaluation of social networks for health promotion remains in its infancy. Additionally, the majority of programs that have been implemented thus far have targeted primarily well-educated, English-speaking populations. Employing communication technologies that require little reading or health literacy and that can effectively deliver personalized health programs in multiple languages over time are increasingly needed. They include interactive voice-response systems (think airline reservation systems) and “virtual advisors” (e.g., computerized characters that can be programmed to deliver tailored advice and support through a simple touch-screen interface that does not require the use of a computer keyboard or mouse).

Text messaging (short message service, or SMS) has shown promise in a range of health contexts around the world. Texting is a particularly attractive approach in that the majority of cell phones now in use worldwide contain a texting function. Texts can be delivered by a human or computer, can be personalized to the individual over time, and require a limited level of language literacy. Text messaging is more likely to be successful in promoting behavior change when text frequency and content are personalized and when there is follow-up over time. Because the costs of texting vary depending on the mobile phone plan being used, this aspect needs to be taken into account when considering the patient population involved.

Similarly, while there has been an explosion of mHealth apps (currently accessible using smartphones, as opposed to www.sfms.org

simple cell phones) in behavioral health and similar areas, the knowledge base related to what works and what does not remains disconcertingly poor. While thousands of mHealth apps have been developed and hundreds of pilot studies have been conducted to test such apps and other health IT programs, many of the studies thus far have lacked rigorous design, a sufficiently long evaluation period, and/or deployment in real-world settings suitable for evaluating whether such programs could be scaled up for broader implementation.

In response to such issues, a growing number of researchers and app developers have called for new ways to design, test, and disseminate evidence-based mHealth programs in a time frame more appropriate to the continual innovation occurring in the field. Among the paradigm-shifting strategies that are being increasingly applied are adaptive intervention methods. Such methods allow for real-time optimization of program components for different patients. Another potential paradigm-shifting strategy concerns the use of crowdsourcing techniques that harness the potential power of citizens in developing and evaluating what types of programs work, and for whom. Along with the promise of such groundbreaking work is the question of whether federal agencies will deem aspects of the current mHealth “frontier” worthy of some greater level of regulation or oversight.

Some Things Health Professionals Can Do

While much of the mHealth field currently remains untested, health professionals can take advantage of the information that is available in considering how to connect their patients with relevant mHealth programming.

Here are some things to consider when looking for mHealth apps or programs:

Personalization wins the day. As in most things related to the health field, there is no “one size fits all” when it comes to the right programs for different people, or for the same individuals over time. This “whiches conundrum” of personalized health (i.e., which programs for which people at which times in their lives) is as relevant in the behavioral health field as it is in pharmacotherapy and other aspects of medicine. Thus programs that offer advice and information tailored to individuals’ needs and preferences over time are recommended. For example, there is evidence that, over an eighteen-month period, brief telephone-based physical activity advice delivered by a personalized automated system can be as effective as human-delivered advice in promoting regular physical activity among initially inactive adults. However, individuals who were less motivated to change their physical activity levels at the beginning of the program fared better with the health educator-delivered telephone program relative to an automated system, while for individuals with higher initial motivation the reverse was true; these individuals had greater improvements in physical activity with the automated system relative to the health educator-delivered program.

The study results indicate that “human touch,” while potent in many health-related circumstances, may not be necessary or even desirable in particular situations or with certain groups of people. www.sfms.org

Look for programs that incorporate behavioral change principles. There is a strong body of evidence, based on decades of research, demonstrating the usefulness of incorporating basic behavioral science principles and strategies into behavioral health programs. Given the current lack of evidence demonstrating which mHealth programs work and for whom, look for programs that contain at least some of the following types of behavioral strategies: personalized, realistic goal-setting focused on specific behaviors, with an opportunity to reset goals as situations change on a regular (daily, weekly, monthly) basis; simple, convenient ways to self-track the health behavior or circumstance being targeted over time; simple, direct ways to receive personal feedback concerning how the person is doing over time via simple displays (for many people, seeing how they are doing in relation to “similar others” can be particularly motivating, given that many people tend to have misconceptions concerning what the general norm is around many behaviors); positive encouragement to motivate continued perseverance when goals are reached as well as in the face of setbacks; harnessing different forms of social support (e.g., encouraging people to reach out to their natural support systems; providing social elements as part of the program through competition or collaborative activities); incorporating fun or other types of motivation as part of the program (as a means of tapping forms of motivation going beyond health); and recognizing how surrounding environmental cues and contexts can influence our behavioral choices and decisions.

It’s never too late to learn how to use technology.

Current evidence shows that the greatest increases in communication technology use are occurring among groups traditionally considered to be lacking in technology skills or interest, i.e., older adults, women, less educated groups, ethnic minorities. This insight has spurred researchers and companies to begin to develop technologies better suited to their needs and preferences.

In summary, as the mHealth movement continues to gain momentum, health professionals will have increasing opportunities to use such technologies as part of clinical care and outreach, as well as to steer patients toward those programs that can make a positive difference in their lives. The challenge will be how best to efficiently link health professionals with the best programs in this fast-paced industry.

Abby King, PhD, is professor of health research and policy and medicine at Stanford University School of Medicine. A clinical psychologist by training, she directs the Healthy Aging Research and Technology Solutions Laboratory at the Stanford Prevention Research Center. Dr. King’s research focuses on the applications of behavioral science theory to the development, evaluation, and dissemination of public health and clinical interventions aimed at chronic disease prevention and control.

May 2013 San Francisco Medicine

15

Technology in Practice

Barriers to New Technology If It Works So Well, Why Aren’t We All Using It? Toni Brayer, MD A friend recently asked me why the health care industry has yet to embrace new, innovative smartphone technology. She had just watched a video about Dr. Eric

Topol, chief academic officer at Scripps Health in San Diego, and his demonstrations of how a smartphone could monitor blood sugar, take EKGs and cardiac ultrasounds, and really deliver health care to the patient at home.

My friend’s question: “If this technology is here, why isn’t it being used?”

According to Dr. Topol, new apps for the smart phones could eliminate 80 percent of echocardiograms that are done in facilities at costs from $300 to $1,500 each. We could eliminate patients needing to come into the office when they experience symptoms, or diabetics coming in to get their blood sugar regulated. New technology could be data driven and personalized and save millions of wasted dollars in health care. So why is medicine so far behind the innovation curve?

The answer: No one pays for it.

Why aren’t all physicians using e-mail to communicate with patients and save them an office visit? The politically correct answer is, “Remote medicine is not as good as seeing the patient in person and making sure the diagnosis is correct.”

The real answer is: No one pays for it.

United States health care has complicated payment systems for work done. The payor for health care services is either Medicare/Medicaid (CMS) or hundreds of different (for-profit) insurance companies. CMS sets the payment rules that everyone follows. Medicare and all insurers will only pay for face-to-face visits. Reimbursement is for doing more, and the more you do the more you get.

The doctor who tries to save a patient time and travel by covering a number of problems in one office visit will not be rewarded and, in fact, will be reimbursed less. If you do a skin biopsy on the same day you do a visit for arthritis flare, CMS and insurance companies will not pay for both things. Do them on separate face-to-face visit days and voilà: a better reimbursement for your time and skill.

E-mail, remote monitoring, remote echo16 17

San Francisco Medicine May 2013

cardiograms, discussing tests via a smartphone are freebies. No patient visit means no reimbursement. The cost of putting in high technology is borne by the physician too.

Most physicians and hospitals and surgery centers and labs and pharmacies are happy with this status quo. There is great fear of change, and so we continue to spend more on health care than any nation in the world. We do wasteful mass screenings, and onethird of all prescriptions are a waste. People who need care are not getting it, and others are getting too much that they don’t need.

ObamaCare is trying to make some gradual changes by supporting pilot programs to change the way health care is delivered.

But it is slow going, and innovative answers are out there. If we could just figure out how to pay for services while using new costsaving technology, we would all be following Dr. Topol’s dream.

Toni Brayer is an internal medicine physician who has practiced for more than twenty years in Northern California. She is a current member and past-president of the San Francisco Medical Society and chief of staff at a large academic medical center. She actively blogs about health care at http://www.everythinghealth.net/.

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m www.sfms.org

Technology in Practice

Your Online Presence What Do Patients Find When They Google You? Debra Phairas and Ashley Porciuncula Managing your online presence involves more than just creating a website. It also includes monitoring your

patient reviews on sites such as Yelp and other MD-rating websites, plus discovering and controlling what your own name produces when searched for on Google, Facebook, Twitter, blogs, and other online resources. It is important to proactively manage your online presence and check the Web frequently to determine patient perception of you and your practice.

Marketing a practice now includes: Assuring that information about you and your practice is accurate and up-to-date.

Knowing what your patients are saying about you as a physician and about your group, your staff, and your practice. Assessing and correcting misconceptions about your practice on review sites such as Yelp, HealthGrades, or RateMDs, and responding proactively to patient complaints. Conveying important information about your credentials and your practice, as well as helpful descriptions of medical conditions, surgeries, and procedures to your patients. Creating efficiencies for your practice and increasing customer service by posting online patient registration forms and/or scheduling appointments.

What Do Your Patients Find When They Google You?

With the exception of the elderly (and even they are techsavvy today), most patients don’t use the telephone book or call information when locating their own physician or finding a new one. They use Internet search engines to quickly find the telephone, address, and website of a practice. If you move your practice, be sure to update your online information immediately. When referred to several doctors, patients will often make decisions based on the information they find online. Take a professional picture of yourself with a warm, smiling face and provide a brief but comprehensive list of your credentials. Include your philosophy of how to treat patients and make it patientfriendly. You may wish to include your hobbies or interests to make yourself more approachable. Profiling staff members is also a good idea. Use search engine optimization (SEO) for your name to appear first on search engines. Registering with online directories will help your name, with location and a map, to be among the first results to appear. You also don’t want the first item to pop up on a search engine to be a negative rating.

Check your online presence once a month and use any negative reviews to correct bedside manner, staff customer service, or office policies and procedures. Do not single out any staff members in meetings but discuss negative reviews with problemsolving for change. Reward positive feedback and make this a part of performance reviews. www.sfms.org

Branding Your Image Create a consistent brand that carries through your website and office materials.

Choose a logo, colors, and style that create a standard for your practice. It can be as simple as the doctor or group name in a font, or a professionally designed logo with an image. For example, one medical oncology and breast surgery practice has a purple iris theme that is carried out in all logos, stationery, brochures, website, and business cards, and the practice gives the patient a vase with a purple iris after surgery. If you are profiled in TV, radio, newspapers, or online magazines, place a clip or link on your website. This allows your patients to view this “third-party endorsement,” giving you additional credibility.

Ostensible Agency

Whether the group is an expense-share arrangement of solo practices, a combination of practices, or a sole proprietor/corporation that uses a group name, the group is creating an ostensible agency/partnership and thus has the same liability as a true, integrated group. Many physicians are unaware of this legal doctrine. This holds that if the public, patients, and other physicians think the group is a true integrated group, then the group is all liable for all members just as if they were a true group. Review CMA on-call legal documents on this subject or contact your malpractice carrier. All websites, stationery, business cards, and signs on walls and doors must be clear that this is an association of independent practices.

Social Media

You may want to join one of the popular social networking websites, such as Facebook, Twitter, LinkedIn, or others that are relevant to your business. Joining these websites gives you a face and the ability to more proactively manage your online image. Have new staff sign your office personnel policies and procedures, stating that they will not use social media sites during work hours unless they are specifically charged with updating your website or profiles. Make it clear that harassment of staff or revealing patients of the practice via social media is a breach of confidentiality that can be grounds for termination.

Blogs

Writing short posts about something newsworthy or educational about yourself, your specialty, or medical issues helps you stay relevant. Adding this to your website will in-

Continued on page 19 . . .

May 2013 San Francisco Medicine

17

Technology in Practice

Health Care Texting Maintaining a HIPAA-Compliant Environment Andrew A. Brooks, MD I’m often amazed at how little health care communication has changed in the nearly twenty-five years since I was a medical student. The last great in-

novation was the introduction of the pager.

In most hospitals, the communication process among physicians is arcane, inefficient, and potentially dangerous as it relates to patient care. According to the Joint Commission, a breakdown in communications could be tied to more than 60 percent of all reported sentinel events in 2011.

To improve communication efficiency with other physicians, hospitals, or their offices, many physicians are turning to smartphone technology—specifically Short Message Service (SMS) text messaging. But in doing so, are they potentially exposing themselves to unrecognized liabilities? This article explores some of the key facts related to text messaging in the health care environment and what orthopedic surgeons need to know. SMS text messaging can improve communication among health care providers, but it may also increase liability risks.

An Effective Communications Tool

Text messaging has become a major part of social communication in today’s society. It’s efficient, allows information to be transmitted asynchronously and succinctly, and can thwart unnecessary or prolonged conversation.

Compared to e-mail, with its seemingly endless number of spam messages, texting serves as a priority communication channel. Because people may be more reluctant to share cell phone numbers than e-mail addresses, the group who can text an individual is usually more restricted and trusted.

Although text messaging has obvious social communication advantages, it also has clear utility in health care. Texting is fast, direct, and simplifies the traditional, laborious pager and callback work flow that hospitals and other organizations have used for years.

For example, a study conducted by the Robert Wood Johnson Foundation found that nurses waste as much as sixty minutes of each work day tracking down physicians for a response.

Imagine the cumulative waste of time and added labor costs across our entire health care system these delays have caused.

So What’s the Problem?

Unfortunately, traditional SMS messaging is inherently nonsecure and noncompliant with safety and privacy regulations under the Health Information Portability and Accountability Act (HIPAA). Messages containing electronic protected health information (ePHI) can be read by anyone, forwarded to anyone, remain unencrypted on telecommunication providers’ 18 19

San Francisco Medicine May 2013

servers, and stay forever on sender’s and receiver’s phones.

In addition, senders cannot authenticate the recipient of SMS messages (that is, senders cannot be certain that the message has been sent to and opened by the right person). Studies have shown that 38 percent of people who text—including me —have sent a text message to the wrong person.

As a result, the Joint Commission has effectively banned physicians from using traditional SMS for any communication that contains ePHI data or includes an order for a patient to a hospital or other health care setting. A single violation for an unsecured communication can result in a fine of $50,000; repeated violations can lead to $1.5 million in fines in a single year, not to mention the reputational damage done to an organization and its ability to attract patients.

A recent case, for example, resulted in a $50,000 fine to the provider. In addition, the provider was required to “implement security measures sufficient to reduce risks and vulnerabilities to ePHI to a reasonable and appropriate level for ePHI in text messages that are transmitted to or from or stored on a portable device.”

HIPAA‐Compliant Texting

The Joint Commission did not ban all text messaging solutions, however. Instead, it established Administrative Simplification (AS) provisions that serve as guidelines for developing secure communication systems. Under the AS guidelines, the following four major areas are critical to compliance:

Secure data centers. Health care organizations typically store patient information in either onsite or offsite (cloud) data centers. HIPAA requires these centers to have a high level of physical security as well as policies for reviewing controls and conducting risk assessment on an ongoing basis.

Encryption. AS stipulates that ePHI must be encrypted both in transit and at rest.

Recipient authentication. Any communication containing ePHI must also be delivered only to its intended recipient. A texting solution should allow the sender to know if, when, and to whom a message has been delivered.

Audit controls. Any compliant messaging system must also have the ability to create and record an audit trail of all activity that contains ePHI. For a text messaging system, this includes the ability to archive messages and information about them, to retrieve that information quickly, and to monitor the system. www.sfms.org

Standard consumer-based messaging systems fail most of these requirements. The data centers are often not designed with the highest levels of physical and data security. Messages can be intercepted and are not encrypted. Recipient authentication is not available and, although messages and delivery details may be stored indefinitely, they are not designed to provide a fully functional audit trail.

Secure Text Messaging Solutions

By using a private, secure texting network, doctors, nurses, and staff can not only send and receive patient information but also potentially achieve the following goals: shorten response times; improve the accuracy of decision making by having better information; allow multiple parties involved with clinical decision making to be looped in on the same message; allow for quicker interventions and improved patient outcome; securely communicate lab results, imaging results, patient procedures, and medical histories, allowing the physician to have more information readily available; speed up on-call notifications; eliminate the hassle of callbacks; integrate with scheduling systems to create automatic notifications of pending events.

In today’s increasingly mobile world, technology will undoubtedly continue to be a massive driver of greater efficiency.

Physicians are typically eager to embrace and adapt new technologies. Used properly, texting technology has the potential to revolutionize the quality of how health care is delivered to patients.

Andrew A. Brooks, MD, is an orthopedic surgeon and cofounder and chief medical officer of Tigertext, a secure mobile messaging platform designed to help hospitals and businesses improve workflow and reduce risk. Reprinted with permission from AAOS Now, the journal of the AAOS August 2012 issue. http://www.aaos.org/news/aaosnow/aug12/managing5.asp

Reference 1. www.jointcommission.org/physicians.aspx.

Your Online Presence Continued from page 17 . . . crease your search ratings and get your message out.

Links to Other Medical Websites

Why have patients view websites that may contain inaccurate or biased medical information when you can provide them with medical sites you know are trustworthy? Put links on your website to your medical or specialty societies and to other organizations you would want patients to view.

Debra Phairas is president of Practice & Liability Consultants. Ashley Porciuncula is a website designer with more than ten years of experience. Practice & Liability Consultants, LLC, offers logo and website design services. See sample sites at www.practiceconsultants.net. www.sfms.org

New Recommendations Offer Physicians Ethical Guidance for Preserving Trust in PatientPhysician Relationships and the Profession When Using Social Media The American College of Physicians and Federation of State Medical Boards recently released a policy paper encourage doctors to always “pause before posting” and not to “friend” patients.

Notable recommendations from ACP and FSMB include: • Physicians should keep their professional and personal personas separate. Physicians should not “friend” or contact patients through personal social media.

• Physicians should not use text messaging for medical interactions even with an established patient except with extreme caution and consent by the patient.

• E-mail or other electronic communications should only be used by physicians within an established patient-physician relationship and with patient consent.

• Situations in which a physician is approached through electronic means for clinical advice in the absence of a patientphysician relationship should be handled with judgment and usually should be addressed with encouragement that the individual schedule an office visit or, in the case of an urgent matter, go to the nearest emergency department.

• Establishing a professional profile so that it “appears” first during a search, instead of a physician ranking site, can provide some measure of control that the information read by patients prior to the initial encounter or thereafter is accurate.

• Many trainees may inadvertently harm their future careers by not responsibly posting material or actively policing their online content. Educational programs stressing a proactive approach to digital image (online reputation) are good forums to introduce these potential repercussions.

The paper includes a chart of online activities, potential benefits and dangers, and recommended safeguards for physician behavior.

For example, communicating with patients using e-mail offers the potential benefits of great accessibility and immediacy of answers to non-urgent issues. The potential dangers are confidentiality concerns, replacement of face-to-face or phone interaction, and ambiguity or misinterpretation of digital interactions. The safeguards include reserving digital communications for patients that maintain face-to-face follow-up only.

The paper was published in the April 16 issue of Annals of Internal Medicine and was authored by ACP’s Ethics, Professionalism and Human Rights Committee, ACP’s Council of Associates, and FSMB’s Committee on Ethics and Professionalism.

For more information and to read the entire paper, visit http://bit.ly/10RfiWj. May 2013 San Francisco Medicine

19

Technology in Practice

A Secure Platform DocBook Leads the Way in Secure Health Care Communications Tracy Haas, DO, MPH Doctors love smartphones; in fact, more than 80 percent are using one today. As mobile communication

in the health care arena continues to gain traction, penalties for HIPAA violations are growing while medical errors due to lack of communication are on the rise. Not to ignore the increasing pressure providers are feeling to reduce health care costs in general. A solution is in order.

There have been many efforts recently that aim to lower medical costs for patients, but few that would also improve health outcomes, such as opening communication between physicians.

According to a recent study of Medicare claims, for every 100 Medicare patients a primary care provider sees, they must coordinate care with ninety-nine other physicians across fifty-three specialties.1 This has opened the door to a rise in serious medical errors due to miscommunication between health care providers. JCAHO estimated that up to 80 percent of serious adverse patient events are due to poor communication between health care providers.2

Many believe medical errors are largely due to deficiencies in medical knowledge, but, actually, twice as many deaths in the hospital are due to lack of communication than to medical incompetence.3

With an increased number of medical specialties and demand for large coordinated medical teams, particularly for patients with chronic illnesses, there is new need for communications reform along with health care reform.4 With electronic medical records being adopted slowly and perhaps under duress, physicians simply do not see the benefit in learning one more gadget, especially if it means a new cost of use, a new learning curve, and security issues that could lead to increased liabilities.

However, there is one platform physicians and health care providers are already familiar with: mobile devices. According to a report by Manhattan Research, which tracks technology use by health care providers, 81 percent of U.S. physicians are currently using a smartphone,5 and another survey found iPad adoption among physicians to be five times higher than that of the general population.6 The adoption rate for smartphones and tablet devices is high, but so are the penalties for HIPAA violations associated with improper uses on those devices. With penalties of $50,000 per violation, and up to $1.5 million in fines for any one individual, malpractice carriers as well as hospitals and 20 San 21 SanFrancisco FranciscoMedicine Medicine May May2013 2013

large practice groups are paying attention to secure mobile communications platforms.

When it comes to health IT, observes Dr. Tim Gueramy, MD, orthopedic surgeon and cofounder of DocbookMD, everyone is trying to solve the wrong problem. “Companies are trying to take enterprise-wide solutions and force that technology into medicine. Instead, at DocbookMD, we’re asking, ‘Why do physicians need this technology, how can it adapt to the way they work, and ultimately how will it help them and their patients?’”

Based on their own experiences, Dr. Gueramy and Dr. Tracey Haas founded DocbookMD because they know that if physicians can communicate quickly and efficiently, patient care is better. “Communication saves lives,” says Haas. “It’s as simple as that.”

DocbookMD is an exclusive HIPAA-compliant messaging application for smartphone and tablet devices. Through DocbookMD, physicians can send secure messages to other physicians, bundled with photos of X-rays, EKGs, or other patient information. The result is faster and richer consultations on patient care and treatment.

From the physician who called off surgery at the last minute because of an abnormal lab sent by the anesthesiologist to the cardiologist who was sent an EKG by an ER doctor and was then able to talk the ER doctor through an intervention, DocBookMD, by putting doctors in control, enables the kind of immediate, secure communication that can change the face of health care.

As of October 2012, DocbookMD has 11,500 physician users in twenty-eight states and continues to grow. Gueramy says, “In the past few months we’ve significantly expanded our market share in Florida and Missouri, as well as launching in Nebraska, Oregon, Montana, and Georgia.”

Today, DocbookMD is being configured so that a physician can add any DocbookMD message into the patient record.

It is also poised to expand as a tool for wider patient-care teams, in order to help with care coordination across any type of practice setting.

In an age when physicians have become buried in a sea of penalties, rising costs, and mandates, DocbookMD provides a technological solution that makes it easier to do the job.

DocBookMD is a free HIPAA-compliant communication tool provided exclusively for SFMS and other county medical society members.

Tracey Haas, DO, MPH, is a family physician and cofounder/chief medical officer of DocbookMD. References available at www.sfms.org/NewsPublication/SFMSBlog.aspx. www.sfms.org

Technology in Practice

E-mailing Patients Does Your Office Have Written Guidelines?

We’ve all gotten comfortable using e-mail, but in a medical office setting privacy and security cannot fall by the wayside when using this technology. MIEC recommends all medical practices have a written set of guidelines that both patients and medical office staff and physicians are aware of.

The guidelines should inform patients: (a) about the limitations of using e-mail, (b) that messages/inquiries should be brief, (c) about the possibility that e-mail will not be received in a timely manner, (d) what to do if their e-mail inquiries are not answered in a timely manner, (e) about the possibility that improperly-addressed messages or replies could be received by unauthorized persons, and (f) that reporting medical problems to the doctor by e-mail may not be a safe alternative to seeing the doctor.

Inform patients that they must decide if their request can appropriately be satisfied by e-mail. They must obtain an appointment or a telephone consultation with the doctor it they believe their medical need is significant.

Ensure security of your electronic communication to protect patient confidentiality. Take basic safeguards, such as having an extremely secure password not used for any other purpose and

www.sfms.org

password protecting any smartphone you use for e-mail. You can also request that a patient confirm his or her e-mail address before you begin communicating about sensitive information.

Another safeguard against potentially misdirected e-mail is to add a disclaimer to online responses transmitted to patients.

For example, include the notice, “This message is intended only for the use of the individual(s) or entity to which it is addressed, and may contain information that is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you received this communication in error, please notify the sender immediately by e-mail. Thank you for your assistance.�

Portions of this article were excerpted from the newsletter of the Medical Insurance Exchange of California. MIEC is a not-forprofit, physician-owned professional liability insurance carrier founded in 1975 by SFMS and five other Northern California county medical societies. For more information, visit http://www.sfms. org/Membership/MembershipBenefits/MIEC.aspx

May 2013 San Francisco Medicine

21

Technology in Practice

Is Skype HIPAA Compliant?

Video Conferences and Patient Confidentiality Rene Y. Quashie Is Skype HIPAA-compliant? This is probably the question I get asked the most. For the sake of this article, I am using the term Skype to include Skype and similar free Web-based communication platforms relying on proprietary voice-over Internet technology.

As with so many things, the answer is complicated. But the question itself is misleading. Many vendors and manufacturers market their technology and products using terms such as “HIPAA compliant.”

However, products or technology cannot themselves be HIPAA-compliant. Hospitals, providers, and other covered entities are the ones who are either HIPAA-compliant or not. In other words, it is providers and practitioners who need to be HIPAA-compliant, not products or technology. Covered entities do need to ensure that any technology or products they use be compatible with HIPAA standards so that they, as covered entities, can comply with their HIPAA obligations.

So the real question should be whether Skype or similar platforms are compatible with HIPAA standards. And the use of Skype raises many HIPAA issues: Many platforms are proprietary, cannot reliably develop and verify an audit trail, may not know when a breach of information occurs, have no way to verify transmission security, and lack integrity controls.

Among other things, the HIPAA rules require access control, audit controls, person or entity authentication, transmission security, business associate access controls, risk analysis, workstation security, device and media controls, a security management process, breach notification.

The use of Web-based platforms, especially those that are proprietary, may make it difficult for health care entities to meet some of these obligations. At the very least, I think that use of Web-based platforms for patient communication carries higher risk of potentially violating HIPAA rules. And this is becoming increasingly important with all of the heightened HIPAA enforcement activity we have been seeing.

The Health Information and Trust Alliance and other organizations generally recommend against the use of Skype and similar platforms for communications involving health information. All of this does not mean a telepsychiatrist or other professional should not use Skype to communicate to patients—only that they be aware of the increased risk. There are some things I would recommend providers consider to better protect themselves from potential HIPAA liability: Request audit, breach notification, and other information from companies; have patients sign HIPAA authorization and separate informed consent as part of intake procedures when using Web-based platforms; develop specific procedures regarding use of Skype and similar platforms (interrupted 22 23

San Francisco Medicine May 2013

transmissions, backups, etc.); train your workforce on the use of these platforms; exclude the use of these platforms for vulnerable populations (i.e., the severely mentally ill, minors, those with protected conditions such as HIV); limit their use to certain clinical applications (i.e., only intake or follow-up); and use secure platforms with audit trail, breach notification, and other capabilities.

Ultimately, my view is that providers proceed with great caution when using Skype or similar platforms. The beauty of Skype is that it is free. Of course, it is always better to use fully encrypted and more secure technology when dealing with patients. But I realize that is not always an option, given costs and logistics. So, if providers choose to use Skype, they may want to start by considering some of my recommendations.

Rene Y. Quashie is a senior counsel in the Health Care and Life Sciences practice in the Epstein, Becker, Green law firm’s Washington, D.C., office. He focuses his practice on federal regulatory and administrative health care matters, including Medicare and Medicaid, legislative and health policy, privacy and security, general compliance, clinical research, health information technology, FDA issues, and telemedicine.

This article was reprinted with permission from http://www. techhealthperspectives.com/.

Summer Workshop in Clinical Ethics For Hospital Ethics Committee Members Saturday, June 8, 2013 California Pacific Medical Center (Pacific Campus) Belmont to the Bedside: Translating the Principles of Ethics to the Practice of Medicine: The Belmont Report (1979) is often referred to as the Bedrock of Bioethics. This Workshop offers a unique opportunity to revisit the principles stated in the Belmont Report though the eyes of one of its authors, the Program in Medicine and Human Values’ senior scholar, Dr. Albert Jonsen. We will focus on the relevance of the goals espoused in that document to clinical medicine in the twenty-first century. The afternoon session will explore three clinical issues that are commonly encountered in the process of clinical ethics consultation: decision making for the unrepresented, obligations to the challenging patient, and assessing a patient’s capacity to express their values and preferences for medical treatments.

Registration: See cpmc.org/ethics

www.sfms.org

Technology in Practice

Selecting an EHR Questions to Ask About Your Practice and the Vendor Kimbelee Snyder With more providers trying to reach CMS requirements for meaningful use, the selection of an electronic health record (EHR) can be overwhelming.

The focus on EHR implementation continues as a priority for clinicians as 2015 approaches, when eligible providers will start receiving CMS payment adjustments for not achieving meaningful use.

Selecting an EHR is a task that requires careful planning and analysis prior to entering into an agreement with an EHR vendor. Starting with identification of key goals and objectives, a practice should also analyze any unique work flow requirements impacting EHR selection. Once those items are complete, the provider can invite selected vendors to demonstrate their EHRs.

Top questions to ask when selecting an EHR • Is the EHR cost within my budget?

• Does the EHR’s functionality fit my practice requirements?

• Do existing templates work for my specialty and can one easily create new templates?

• What structural or operational changes will I need to perform for EHR implementation?

• Can the vendor support my ongoing needs?

• Who will ensure that all information technology is functioning, not just my EHR software?

Practice Readiness Assessment

Practice readiness assessment is the task of determining whether the practice is ready for transformation to an electronic health record. This is the prework that leads up to vendor selection and is comprised of determining who will lead the EHR project, the project budget, and current work flow analysis.

It is critical that the practice have a champion who will lead the effort toward EHR selection and implementation.

Staff members should be asked for their input as well. For a large practice, a team should be in place to facilitate the EHR selection. For a small practice, it may just be the provider and one or two office staff. One person should be designated as the project manager to handle questions, meetings, and issues.

Once the EHR team has been selected, it’s important to outline the goals and objectives of the project. This ensures that everyone is on the same page regarding the practice transformation efforts.

Budget is a critical component when assessing practice readiness. The budget projection should include the licensing cost of the EHR, the yearly maintenance cost, any custom interfaces needed (e.g., immunization interface), and hardware needs (including new PCs, tablets, Internet connectivity, servers, and printers). Loss of staff productivity during and immediately after implementation should be part of the budget, as there are tasks that the staff will need to work on outside of the patient visits. There are several ways to mitigate loss of productivity, and these should be discussed with the vendors.

Finally, a practice entering into EHR selection should review the office work flow to identify any unique requirements.

For instance, ophthalmology has specialized medical devices that typically need to interface with the EHR. This should be part of your requirements documentation when outlining www.sfms.org

work flow. Also, evaluate work flow from patient check-in to departure to determine areas of improvement and gaps in work flow. Document work flow using a simple flowchart or an outline of each process performed by staff and providers.

Translate work flow requirements into a checklist for use during EHR demonstrations. The list can also be distributed to vendors to help guide demonstrations.

Other questions of importance include: • Is the system certified for meaningful use?

• How long does it take to implement the EHR? • What role does the vendor have in the implementation?

• How much time will the practice spend on the imple-

mentation?

• How many providers are using the EHR in the providers’ region?

• Is the vendor financially stable?

• Is the EHR HIPAA compliant?

• How large is the help desk support team and what hours are they available?

• If a contract is signed, how long before the implementation begins?

• Will the EHR vendor assist in other aspects of information technology (IT) use, such as Internet connectivity or hardware maintenance? If not, how will the practice get that assistance? For example, will a separate IT vendor be required?

EHR Vendor Demonstrations

The first step toward EHR demonstrations is selection

Continued on the following page . . .

May 2013 San Francisco Medicine

23

Selecting an EHR Continued from the previous page . . . of vendors who appear to meet the requirements outlined in the practice readiness phase. Be sure to consider any unique requirements you have. For pediatricians, a system that’s flexible with scheduling and has the templates for growth charts and immunization records will be needed. An endocrinologist will need an EHR that has templates for growth hormone disorders and diabetes visits. Typically, a provider should select three EHRs for demonstration.

During the demonstrations, request that the vendor walk you through a visit from patient check-in to patient check-out.

The demonstration should be modeled after both a typical office visit and a nontypical visit. The ability to quickly and easily move through the EHR when the patient visit expands beyond its initial reason should be demonstrated as well. Usability of the template features should be demonstrated; the provider can also ask to set up a template.

Ask every vendor for a sample of their standard contract; service level agreement; and a sample project schedule, with roles and responsibilities assigned. This is also a good time to ask for vendor references to begin the process of getting others’ reactions and opinions regarding the EHR being evaluated.

Once the demonstrations are complete, the practice or practice team should review the functionality of each EHR. Using the checklist created during the work flow analysis, the practice can determine which EHR fits the practice needs.

Check references for the vendors and review sample contracts and project schedules. When the final decision is made, a working partnership is formed, and it’s important to know as much as possible about the vendor.

A final quote and contract will be presented once the provider decides on the EHR. Have an attorney familiar with EHR contracts and pricing review the contract. Make sure to ask the vendor about any “hidden costs,” such as extra consulting fees or interface costs. Also, be sure to review the service level agreement and one-time implementation fees.

To learn more about EHR and meaningful use, please visit www.cms.gov.

Kimbelee Snyder is vice president, Health Informatics for Lumetra Healthcare Solutions. Kim and her team of health informatics experts have worked with more than 800 providers, transforming health care practice through the use of electronic health records. She has more than twenty years of experience in organizational leadership, strategic planning, and information systems development and implementation.

24 25

San Francisco Medicine May 2013

Breathe Again !!

CALIFORNIA SINUS CENTERS & Institute CARE for: Atherton (Stanford area) | Walnut Creek (EastWe Bay) | San Francisco Bacterial Infections / Sinusitis

We CARE for:

Functional Endoscopic Sinus Surgery Imaged Guided Surgical Navigation Revision - complex cases

Frontal Sinusitis Bacterial Infections/Sinusitis Culture directed treatment Advanced endoscopic techniques Functional Endoscopic Sinus Orbital Decompression/ Sinuplasty surgery WITHOUT packing Surgery Grave’sSinus disease Nasal obstruction / Septoplasty Fungal Sinusitis Imaged Guided Surgical Tear DuctAllergic surgery— Culture directed treatment Navigation WateryOrbital eyes Decompression / Grave’s disease Duct surgery - Watery eyes Revision–complex cases SinonasalTear tumors/polyps Sinonasal tumors / polyps Smell / Taste Problems Frontal Sinusitis Smell/Taste Problems Complications of Prior Surgeries Advanced endoscopic Complications of Prior CSF leak repairs Mucoceles / Abcesses techniques Surgeries In-office CT scanner Sinuplasty CSF leakUrgent repairs appointments Joint care: ENT- Allergy - Pulmonary Sinus surgery WITHOUT Mucoceles/Abcesses Atherton (Stanford area) packing In-oPce CT scanner Walnut Creek (East Bay) Nasal obstruction/ Urgent appointments San Francisco Winston VaughanMD David Kathleen LowNP Sherry PeterClark, KillianMD Kathleen KarenDerakhshandeh Fong, MD Winston Low, Vaughan, Sacramento Joint care: ENT–Allergy– MD PA-C Septoplasty MD NP Allergic Fungal Sinusitis Pulmonary

www.CalSinus.com

www.CalSinus.com

Karen Fong MD

Winston Vaughan MD

Sherry Derakhshandeh PA-C

Kathleen Low NP

Report: Few Doctors Want Full EHR Access for Patients Many U.S. physicians believe that patients should play an active role in updating their electronic health records, but few doctors want to provide patients with full access to their EHRs, according to a new report from Accenture. The report found that 31 percent of surveyed U.S. doctors said they were willing to provide patients with full access to their EHRs, while 65 percent said they were willing to provide patients with limited access to their EHRs. Four percent of doctors said they were not willing to provide patients with any access to their EHRs. “Most Docs Don’t Want You to See Your Full Electronic Medical Record” (Pavgi, “Health IT Update,” NextGov, 3/5).

“Poll: Patients Should Be Allowed to Make EHR Updates, but Not Have Full Access” (Hall, FierceHealthIT, 3/5).

Reprinted from http://www.californiahealthline.org/ articles/2013/3/8/report-few-doctors-want-full-ehr-accessfor-patients.aspx#ixzz2Os3vkKsb. www.sfms.org

Technology in Practice

Robotic Surgery in Gynecology The da Vinci Surgical System

Minimally invasive surgery (MIS) has become the centerpiece of gynecologic surgery in the last decade. This includes laparoscopy, vaginal surgery, hysteros-

copy, and robotic surgery. Although laparoscopy started in the 1920s , laparoscopic hysterectomies did not take off in the United States until the 1990s, and by 2003 they accounted for only 12 percent of hysterectomies preformed. The da Vinci robotic system was invented in 2001, originally for use in the military. It involves laparoscopic ports that are docked to a “robot,� allowing for wristed instruments that are controlled at a surgical console. It gained FDA approval in 2005 for gynecologic surgery. Da Vinci robotic surgery now accounts for 20 percent of the hysterectomies performed in the U.S. and has applications in gynecologic oncologic surgery as well as for treatment of other benign conditions, such as myomas and endometriosis.

More than 75 percent of gynecologic uterine cancer surgeries in the U.S. are performed on the robotic platform.

The exciting thing for me, as a gynecologist, is seeing how many MIS procedures are being done currently as compared to when I trained as a resident in 1994. Robotic surgery has allowed us to push the envelope and offer a minimally invasive approach to a wider variety of patients: high BMI, complex pathology, surgeries requiring a lot of suturing. The robotic platform has also shortened the learning curve for individuals who found laparoscopy challenging. As with all new technology,

Favorite Apps for Doctors drawMD Helps physicians create detailed, interactive visuals to easily explain complex issues and procedures.

Upper Respiratory Virtual Lab Explore the upper airway with a 3D simulator.

Anatomy on the Go Flashcards Perfect your understanding of anatomy.

CORE Orthopedic Exam Your portable, expert

reference tool for diagnosing musculoskeletal and orthopedic disorders.

Diagnosauras DDX Quick-reference tool for performing differential diagnosis at the point of care.

ECG Rhythms Just like a real ECG monitor on your phone.

Epocrates Drug and disease reference tool. www.sfms.org

Leslie Kardos, MD

there is a learning curve associated with robotic surgery. There is special training on the device, animal labs, and proctored training on patients. The challenges that we face as a specialty are many. We must delineate who should train, how they should be credentialed, and how to incorporate robotic surgery into our training programs. We must also be a responsible society and continue to evaluate cost and the impact of cost on our delivery of health care.

At CPMC, I have had the privilege of helping to start the robotic surgery program. While it started with urology, gynecology is now the leader in volume of cases done. We also have general surgery and cardiac surgery at our institution.

The majority of gynecologic cases are done on an outpatient basis, with the remaining few patients admitted only for twenty-three-hour observations. We have been able to take major abdominal cases, convert them to MIS cases, and send patients home the same day. Our patients are back to their regular activities within two weeks, with minimal discomfort or disruption to their lives.

Next on the horizon is single-site robotic surgery performed through a small umbilical incision. Stay tuned!

Leslie Kardos, MD, is director of robotic surgery in the division of gynecology at CPMC. She is also a member of the SFMS.

Medical Spanish (with audio) Helps you obtain a history, physical, and manage a Spanish-speaking patient in nearly any setting.

Medical Terminology and Abbreviations Quick Reference Like having a comprehensive medical

dictionary in your pocket.

Pocket Lab Values Quick access to common and uncommon lab values, important clinical information, critical lab values, differential diagnoses, tube colors, and more.

DocBookMD Connect with colleagues in a secure platform via your smartphone. Share X-rays, labs, and more.

DynaMed Evidence-based clinical reference. Updated daily.

ICD-9pcp For quick look-up of codes. bones-lite An anatomy game.

Compiled the editorial board of San Francisco Medicine25 Mayby2013 San Francisco Medicine

The Orthopedic Leaders in San Francisco • • • • • • •

Anterior Approach Hip Replacement Partial Knee Replacement Total Joint Replacement Spinal Surgery Sports Medicine Podiatry Pain Management

Call 866-466-1401 to refer to one of our specialists.

Saint Francis Memorial Hospital Bush at Hyde Downtown

27

San Francisco Medicine May 2013

St. Mary’s Medical Center

Stanyan at Fulton Across from Golden Gate Park saintfrancismemorial.org stmarysmedicalcenter.org www.sfms.org

Technology in Practice

Biomechanics An Update from the St. Mary’s Lab Jim Zucherman, MD Northern California’s premier biomechanics laboratory moved to St. Mary’s Medical Center Campus in 2010 from San Francisco General Hospital.

Biomechanics laboratories are key to the development and understanding of many surgical technologies, especially implants and approaches in orthopedic surgery. Under the direction of Jeremi Leasure, director of the laboratory, the Taylor Collaboration was formed as a nonprofit consortium of clinicians and engineers. The laboratory interfaces with the San Francisco Combined Orthopedic Residency Training Program faculty, residents, and fellows based at St. Mary’s Medical Center. Surgeons from orthopedic staff at St. Mary’s, neurosurgeons, pediatric surgeons, and neurophysiologists from UCSF run studies with the five in-house engineers and support staff to evaluate surgical procedures and concepts.

The laboratory specializes in mechanical testing of medical devices and investigation of surgical outcomes. There are currently forty-two research projects running in the lab. Many of these are conducted by orthopedic surgery residents from the St. Mary’s program. This nonprofit organization fosters communication between diverse fields of expertise. It is a fertile think tank to not only improve existing technologies and their understanding but to lead to new treatments and innovations. Numerous start-up companies also use the lab to evaluate products for efficacy prior to and during clinical evaluation.

Leasure’s full-time team includes two mechanical engineers and a bioengineer, an industrial design engineer, a lab manager, and a business manager. Part-time support staff include ten postbaccalaureate engineering and undergraduate researchers from UCB, SFSU, Cal State East Bay, and other schools; a PhD candidate of epidemiology and biostatistics from UCSF; a grant writer; and a publication coordinator. The REDDI program summer internship was organized to develop the skills of engineers and researchers in orthopedics. The program provides a structure where the participants are introduced to the equipment, methods, and concepts of orthopedic biomechanics, clinical outcomes, and device design/ development. Undergraduates and secondary school students are also offered educational experience in the lab during summer holidays.

The Taylor Collaboration has received funding from diverse sources. Private grants from foundations include the Luke B. Hancock Foundation, Lloyd Taylor Education Fund, Orthopedic Research and Education Foundation (OREF), Omega Grants Association, and private corporation grants from DePuy Synthes, Stryker, Arthrex, Medtronic, and AO/ Synthes. Additional funding comes from small companies in www.sfms.org

the innovation stage, St. Mary’s Hospital, and the San Francisco Combined Orthopedic Residency Training Program.

The Taylor lab includes 2,500 square feet of space on St. Mary’s campus. It houses a cadaver lab, two Instron testing frames, a machine shop with computer mill, lathe, 3-D printer, CAD suites, and a portfolio of testing fixtures.

In its short history the lab has been quite fruitful. Published works have discussed the specific strength of bone in different parts of the spine and the great implications this has on the ability and ways to grab bone to repair spinal deformity in the osteoporotic patient. A mapping technique using widely available CT scan software was developed by the lab and St. Mary’s orthopedic staff. In deformity spinal surgery, the forces are so great that the fixation metal rods can break. The lab has shown that the way and amount of bend will determine the chance of breakage. The lab developed a technique to correct the weakening caused by bending of the fixation rods. Evaluation of the specific causes of shoulder stiffness in frozen shoulder has been published. The spine can be surgically approached from the posterior or the anterior, and spinal stenosis is usually corrected from the posterior approach by laminectomy; the lab showed that correction of spinal stenosis is actually greater by restoring the height of the usually collapsed disc spaces from an anterior transabdominal or trans-psoas approach.

Several start-up companies are developing products at the site. Similar labs, like the one at Dignity St. Joseph’s Hospital in Phoenix, have been used to develop the Staflex motion preservation device now available in Europe, and the X-stop approved for use worldwide. Also in the works is a new and novel internal spine fixation system. The lab has developed an apparatus to precisely position artificial knee and hip joints and is currently developing techniques for treating cartilage defects. The Taylor laboratory is leaving its mark on professional education, technology advancement, and health care for the future.

Jim Zucherman, MD, is an orthopedic spinal surgeon at the St. Mary’s Spine Center. An SFMS member since 1984, he is the inventor and codeveloper of the X-STOP, the interspinous process device that revolutionized the surgical treatment of lumbar spinal stenosis and the only FDA-approved interspinous process device that does not require fusion and is done under local anesthesia. He also invented the laparoscopic lumbar fusion and the Staflex preservation device, approved for use in Europe, which avoids or minimizes the need for fusions.

May 2013 San Francisco Medicine

27

Act now to avoid Medicare Penalties Advice from the CMA Over the past six years, the Centers for Medicare and Medicaid Services (CMS) have launched a number of initiatives that offer physicians the opportunity to increase their net revenue by participating in quality reporting programs.

Until now, these programs have been voluntary and physicians have received bonuses for participating. That’s about to change.

Failure to participate now means physicians could face significant penalties.

The American Academy of Family Physicians estimates that participating in these initiatives in 2013, rather than waiting until 2014, could save a physician $19,000 in avoided penalties.

To help physicians understand the bonuses and penalties associated with key Medicare initiatives, the California Medical Association (CMA) recently hosted a webinar for members, “Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties.” The webinar is now available for on-demand viewing at www.cmanet. org/webinars.

During the webinar, CMS Region 9 Chief Medical Officer Betsy Thompson, MD, discusses the major quality reporting and e-health incentive programs currently underway for eligible professionals. The session covers the basics of the Physician Quality Reporting System, the Medicare and Medicaid Electronic Health Records Incentive Programs, the Medicare EPrescribing Incentive Program, and the new value-based payment modifier. The content is geared toward physicians, nurse practitioners, and physician assistants and what they need to know, although other health care professionals and medical offices may find the information useful as well.

Below is a brief summary of the programs and key dates that were discussed in the CMA webinar.

Meaningful Use

Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption under the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs. Meaningful use is also the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments, and value-based purchasing.

Bonuses: For the Medicare EHR incentive program, your cumulative payment amount depends on the first year of participation. Physicians who start participating in 2013 can receive up to $39,000; physicians who start in 2014, up to $24,000. The last year to begin participation in the Medicare EHR incentive program is 2014. For the Medicaid (Medi-Cal) incentive program, physicians can receive up to $63,750.

28 29

San Francisco Medicine May 2013

Penalties: Physicians who do not demonstrate meaningful use by 2015 will be subject to Medicare payment penalties.

These reductions increase from 1 to 2 percent of total Medicare charges in 2015 to 2 percent in 2016 and 3 to 5 percent in 2017 and beyond. Medicaid rates will not be adjusted for failure to achieve meaningful use.

Electronic Prescribing

Medicare’s e-prescribing program provides incentive payments for physicians who e-prescribe and payment penalties for physicians who do not.

Bonuses: This year is the last year to receive a bonus for e-prescribing. To qualify for the 0.5 percent bonus in 2013, you must have successfully reported e-prescribing activity for at least twenty-five patient visits between January 1 and December 31, 2012.

Penalties: Starting in 2012, physicians who did not electronically transmit their prescriptions became subject to payment penalties on all Medicare-allowed charges. The penalty in 2013 is 1.5 percent, and 2 percent in 2014.

Physician Quality Reporting System

The Physician Quality Reporting System (PQRS) is a voluntary quality reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries.

Bonuses: Physicians must report on three individual measures or one measures group to receive a 0.5 percent bonus. Physicians participating in a maintenance-of-certification program are eligible for an extra 0.5 percent bonus for a total bonus of 1 percent.

Penalties: The Affordable Care Act calls for PQRS payment penalties starting in 2015. In the 2012 Medicare Physician Fee Schedule, CMS announced that 2015 program penalties will be based on 2013 performance. Therefore, physicians who do not successfully report on at least one individual measure in 2013 or elect to participate in the administrative claims reporting option will receive a 1.5 percent payment penalty in 2015. The penalty goes up to 2 percent in 2016 and beyond.

Value-Based Payment Modifier Program

The value-based payment modifier was mandated by Congress under the Affordable Care Act. It will adjust physician payment based on the quality and cost of the care they provide.

It will take effect in 2015 using 2013 data for groups of 100 or more physicians. By 2017, this modifier will be implemented for all physicians.

Bonuses: Participating physicians may receive bonuses based on their quality and cost scores.

Penalties: Participating physicians may be penalized up to 1 percent based on their quality and cost scores. Physicians who choose not to participate will be docked 1 percent. www.sfms.org

Legislative Leadership day A Physician’s Story of a Trip to the Capitol Katherine Herz, MD Preoccupied by a recent spate of serious diagnoses in my patients in an age of ever shrinking clinical en-

counters, I couldn’t imagine what I would gain from taking a day away from my practice to learn to lobby. What was I doing driving all the way to Sacramento? Talking with our leaders seemed a remote distraction from more pressing priorities.

As soon as I entered the large hall holding our CMA delegation, I remembered why I had thought this would be a good idea. I was surrounded by hundreds of colleagues eager to help guide policy forces that shape our profession and eager to help medicine evolve in response. These were my people— or at least the ones I hope to emulate.

Dr. Richard Pan, Chair of the Assembly’s Health Committee, started us off with a call to action. He helped those of us who might be feeling a tad out of our league to realize we had something of value to offer. Only doctors can tell what it ’s www.sfms.org

like to take care of patients day in and day out. Numbers and rhetoric convey certain truths, but specific stories turn vague ideas into tangible realities. Stories move and enlighten. “Go out there and make change,” Pan encouraged us.

Peter Lee, executive director of Covered California, the state’s health insurance exchange, followed with a summary of the new landscape arising as a result of the Affordable Care Act. Lee explained that the largest implementation phase is about to begin, with insurance coverage expanding to more than 30 million more Americans, about 5.5 million of them in California alone. Approximately 2.5 million of these Californians will be newly eligible for subsidies that help make health insurance affordable. Covered California will be a vehicle for both subsidies and health insurance plans, and the exchange is designing a massive marketing campaign to make sure everyone who is eligible receives the information and help they need to make the best personal decisions. Lee encouraged us all to be resources for our patients and to help with this outreach.

Lieutenant Governor Gavin Newsom gave a keynote address highlighting the disturbing numbers underlying much

Continued on the following page . . .

May 2013 San Francisco Medicine

29

sues of physician reimbursement, training opportunities, and decision-making-support systems.

During our last office visit, a staff member who knows the wonderful SFMS President Shannon Udovic-Constant saw her in the office and approached her with enthusiasm. The staff member thanked Dr. Udovic-Constant her for her advocacy. It matters when you speak, she told us. We doctors are a force. It was a welcome reminder of our own power to shape our future, if only we raise our voice.

SFMS members meet with staff from Assemblymember Ting’s office of current health care policy discussion. He cited a 62 percent increase in health care costs between the state budget of 2007- to 2008 and the current one. These rising expenditures, felt by all, impose pervasive problems. Health care costs are the dominant challenge we face, he said, in balancing not only state budgets but our individual budgets as well.

While it may be tempting to look only at the merits or demerits of a particular proposal, Newsom urged us to consider bills we would be lobbying within a broader context, one that encompasses insurance changes, the dilemma of rising costs, and our professional values. What core principles guide our efforts? A solid core could help us shape a future from the bottom up while we fight specific battles from the top down.

Arguments framed in a broader context and shaped by fundamental values could ideally help guide decision makers toward a shared goal.

Energized by our morning talks, and up to speed on CMA priority issues after a review of key legislation, we set off for the offices of four legislators: Assembly members Tom Ammiano and Phil Ting and Senators Leland Yee and Mark Leno.

I worried that I wouldn’t have anything to say. I wanted to contribute but couldn’t seem to come up with any appropriate clinical vignettes or insights. I felt unsure about how the interactions with busy lawmakers and staff would proceed.

At the first office, our legislator came and went with a brief hello, followed by a meeting in the hallway with one of his staff. We were, quite literally, “lobbyists.” In some ways this put me at ease. The meeting was informal, but the staff member clearly knew her audience and her policy. She honed in on scope-of-practice issues coming up before the legislature, and she explained how her boss would approach his decision on how to vote. SFMS colleagues voiced our collective concerns with ease and alacrity. I could see how this was supposed to be done.

During the next two office visits, I felt moved to speak myself. While unsure of my impact, I was proud of myself for trying. I kept my own values as a physician in mind. (I believe everyone deserves access to quality medical care. I hope to help provide that care in a cost-effective way. In order to achieve these goals I believe we need an integrated health care system), at the same time, I was addressing specific is30 San 31 SanFrancisco FranciscoMedicine Medicine May May2013 2013

Katherine Herz, MD, is a pediatrician at Kaiser Permanente, San Francisco. She completed a fellowship with the Stanford Center for Health Policy in health care research and policy prior to joining the SFMS board of directors.

SFMS leaders meeting with Carlos Machado, Legislative Director of Senator Mark Leno’s office

Andy Calman, MD and Lawrence Cheung, MD ask for Senator Leland Yee’s support of SB 640

www.sfms.org

SFMS Physicians Converge on the Capitol to Meet With Leaders A group of dedicated SFMS physicians joined more than 400 of their

colleagues and medical students in Sacramento on April 16 to bring the voice of medicine to legislators.

During CMA’s annual Legislative Leadership Day, physicians discussed the many threats—and opportunities—facing the Medical students learn first hand about assembly health committee practice of medicine in California.

After a morning of legislative briefings proceedings from committee chair Dr. Richard Pan and guest speakers, including Covered California Executive Director Peter Lee and California Lieutenant Governor Gavin Newsom, the group headed to the Capitol to speak to their legislators about critical legislative issues affecting the practice of medicine in California.

Among the issues discussed with legislators were MediCal reimbursement rates, physician workforce, scope of practice, and the state budget.

Here is a sampling of CMA-sponsored bills and opposed legislation.

SFMS/CMA-Sponsored Legislation SB 640 (Lara): Medi-Cal Cuts This bill will restore the 10 percent Medi-Cal provider rate reductions contained in the 2011-12 state budget. CMA is building a coalition of different providers who have been impacted by the cuts or who, like CMA, are still in court over their implementation. The bill would both eliminate retroactive portions of the cuts as well as stop them going forward.

This will help provide needed stability to the Medi-Cal system as the state prepares for full federal health reform implementations on January 1, 2014.

AB 640 (Salas): California Physician Corps Program Ten years ago, CMA-sponsored legislation to create the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP) to increase access to primary care physicians in medically underserved areas. Although the STLRP has awarded more than $17 million to more than 220 individuals, the high demand for this program means less than one-third of applicants are awarded funding.

This bill will make private practice primary care physicians who commit to practicing in medically underserved areas eligible for loan forgiveness under the STLRP, require applicants to have three years of experience providing health care services to medically underserved populations within a federally designated health-professional shortage area as dewww.sfms.org

Medical students with Lt. Governor Gavin Newsom fined by the U.S. Department of Health and Human Services, and give preference to applicants who agree to practice in a federally designated health-professional shortage area or medically underserved area and who agree to serve a medically underserved population.

Fully Funding the CURES Prescription Drug Monitoring Database The CURES (Controlled Substances Utilization Review and Evaluation System) database is run by the Bureau of Narcotics Enforcement within the Attorney General’s office, and is used to track the prescribing and dispensing of controlled substances such as opioid medications. Funding for the database was drastically cut in a recent budget, and CMA is working on securing state general fund support to adequately upgrade and operate the database.

Providing a fully functional database to be used by law enforcement, physicians, and medication furnishers is a critical piece of CMA’s legislative strategy for 2013, as we will likely see many bills targeting the opioid abuse/diversion/ overprescribing issue.

Continued on the following page . . .

May 2013 San Francisco Medicine

31

Continued from the previous page . . .

SFMS/CMA-Opposed Legislation AB 491 (Hernandez): Practitioners

AB 493 (Hernandez): Pharmacy Practice Nurse

This bill gives nurse practitioners independent practice., meaning they will no longer need to work pursuant to standardized protocols and procedures or under any supervising physician. It would basically give them a plenary license to practice medicine.

AB 492 (Hernandez): Optometric Corporations

This bill allows optometrists to practice ophthalmology. Specifically, it allows optometrists to (1) treat and diagnose any disease, condition or disorder of the visual system, the human eye adjacent and related structures; (2) prescribe and administer drugs, including controlled substances; (3) perform surgical procedures with local or topical anesthetic; (4) order laboratory and diagnostic tests; (5) administer immunizations; (6) diagnose and initiate treatment for any condition with ocular manifestations.

This bill allows pharmacists to (1) furnish and initiate prescriptions for certain medications; (2) provide consultation, training and education to patients about medication therapy, disease management and prevention; (3) participate in multi-disciplinary review of patient progress, including access to medical records; (4) furnish contraceptives (including non-emergency), prescription smoking cessation drugs and devices and prescription medications for travel purposes; (5) order and interpret tests for monitoring and managing efficacy and toxicity of medication therapy; (6) independently initiate and administer routine vaccines. In addition, SB 493 (Hernandez) creates an advanced practice pharmacists who would be allowed to (1) evaluate and manage disease and health conditions in collaboration with other health care providers; (2) perform physical assessments; (3) order and interpret medication therapy related tests; (4) refer patients to other health care providers; (5) initiate, adjust, or discontinue medication therapy in collaboration with other health care providers; (6) participate in the evaluation and management of disease and health conditions in collaboration with other health care providers.

Key Messages on Scope of Practice Bills • Health care reform is providing us with the opportunity to think creatively about new approaches to provider capacity and access to care, but patient safety should not be compromised in the process of adopting new solutions.

• Patients and health care consumers will benefit from policies that leverage the skills, experience, and talents of all care providers. Physicians see many benefits from working collaboratively with other health care professionals to meet patient care demand, but the framework of care delivery should be within the scope of practice that each health care professional is qualified to perform.

• The capacity of the health care system to provide access to quality care is increased by promoting clinical integration 32 33

rather than further fragmentation through scope expansion of mid-level practitioners.

• Technology, including telemedicine, should be fully utilized to link providers in underserved communities.

• Independent practice or the ability to render services that are beyond a providers scope often leads to increased costs through over utilization of tests, overprescribing of medications and excess referrals to specialist.

• SFMS/CMA will be part of the solution and are willing to take a close look at policies that define the relationship between physicians and allied health professionals. However, “independent” or “autonomous” practice is contrary to what Californian consumers have come to expect and need.

San Francisco Medicine May 2013

St. Mary’s Peter Curran, MD

April brings my favorite time of the year: opening day of baseball season. Contemplating the great American pastime, I wonder if there may be coorelates between the business of baseball and the delivery of health care in San Francisco. Major League Baseball earned $6.6 billion in revenues in 2009.

There were eight different World Series Champions in the 2000s, and no team won back-to-back titles during that time. How does this happen? Largely through a practice called revenue sharing. To put it simply, the larger, “richer” market teams, such as the New York Yankees, subsidize the “poorer” teams such as the Pittsburg Pirates. Although the richer team owners do not enjoy paying what is essentially a tax to play, the league as a whole realizes that a baseline financial parity between teams is necessary. In 2009, $433 million transferred between richer teams to the poorer teams. How does this compare to health care delivery? Clearly, there are hospitals faring better financially than others. An argument can be made that everyone is struggling to some degree with the uncertainty of health care reform, decreasing reimbursements, and a sputtering economy. That being said, a fragmented health care system competes against itself for limited resources in reaching for what should be a common goal: providing the best possible care to patients in the entire community. In health care, the administrators are the “owners,” whose main interest is the economic viability of their organizations; the physicians are the “fans,” who can be fickle with their alliances but ultimately care about having a good product.

What is lacking is the “league,” to make it work best for everyone through revenue sharing to meet the needs of the community. This is where the city or county needs to step in to determine what is fair. Improved financial parity between institutions can be achieved by subsidizing basic operating expenses of less financially performing hospitals that provide a substantial amount of indigent care. These “owners” can then use capital to improve the “product on the field” by providing high-quality care and attracting physicians and services to the community.

The danger if the city or county allows health care organizations to compete against each other in silos, is that, ultimately, more hospitals will fail and there will be decreased access to care for patients. www.sfms.org

HOSPITAL NEWS KAISER

SFVAMC

UCSF

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Gropper, MD

At Kaiser Permanente, we’ve embraced technology and our patients are reaping the benefits of improved care and better access to services. Our state-of-the-art electronic health record, KP HealthConnect, has been operational for more than five years now, and we continue to update the system in response to feedback on how best to care for our populations.

Thanks also to an extensive database, provider webpages, and patients’ individual accounts through www.kp.org, we are able to communicate and educate through secure Internet connections. These access points enable us to reach out when it’s time for regularly scheduled screenings, lab tests, and appointments.

For our chronic care patients with such conditions as diabetes or high blood pressure, management of these conditions is streamlined for both providers and patients, and thus we are able to achieve exemplary quality standards and keep our members healthy.

Each doctor has a “My Doctor Online” webpage where members can look up useful health information while also being able to access their medical records, schedule appointments, refill prescriptions, and e-mail their doctors. The easily accessible physician website is www.kp.org/mydoctor.

More recently, our technology initiatives have been geared toward mobile applications, with the launch of the KP Preventive Care app for both Apple and Android platforms. Members can now conveniently look up preventive health advice, manage their appointments, and receive pop-up reminders for flu vaccinations and mammograms, among other alerts.

We have also advanced our telemedicine program with a solid teledermatology service and are now offering video visits to our members in the hope of solving their problems quickly and preventing unnecessary trips to the medical center.

In 2010, the San Francisco VA Medical Center (SFVAMC) launched primary care Patient Aligned Care Teams (PACTs), the VA version of the medical home model. PACTs provide accessible, coordinated, comprehensive, patient-centered care. The teams include the primary care provider, RN, LVN, and medical support assistant. Extended team members include pharmacists, social workers, nutritionists, and behavioral health providers.

Fully implementing PACT took about two years, but it is now operational at the Medical Center and in all six of our community-based outpatient clinics, from San Bruno to Eureka.

Three years later, the PACT model continues to provide our patients with enhanced coordination of care and access, and it has helped reduce hospitalization.

SFVAMC is working hard to increase patient access in a wide range of ways. PACT itself increases the efficiency of the VA medical system by ensuring that all team members work at the top of their licenses. Additionally, SFVAMC has been improving access by increasing non-face-to-face care. One example is the use of telephone visits, as VA providers and other PACT team members recognize that certain types of visits can be accomplished just as well on the phone as in person.

TeleHealth data collection units, which plug into patients’ phone lines, help monitor conditions such as hypertension, diabetes, and heart failure from the patients’ own homes.

Likewise, the VA is promoting and expanding the capabilities of “MyHealtheVet,” a Webbased health care portal for patients that allows them to e-mail their PACT team, renew medications, and view test results and even their actual chart notes. The primary care clinic at the main San Francisco campus will also soon add an after-hours clinic one evening per week and on Saturday mornings.

www.sfms.org

A team of researchers at UCSF led by Edward Chang, MD, a neurosurgeon at the UCSF Epilepsy Center, has uncovered the neurological basis of speech motor control, the complex coordinated activity of tiny brain regions that controls our lips, jaw, tongue, and larynx as we speak. The work has potential implications for developing computer-brain interfaces for artificial speech communication and for the treatment of speech disorders. It also sheds light on an ability that is unique to humans among living creatures but poorly understood.

Spoken words require the coordinated efforts of numerous “articulators” in the vocal tract—the lips, tongue, jaw and larynx—but scientists have not understood how the movements of these distinct articulators are precisely coordinated in the brain.

To understand how speech articulation works, Chang and his team used brain mapping to record electrical activity directly from the brains of three people undergoing brain surgery at UCSF Medical Center, and they used this information to determine the spatial organization of the “speech sensorimotor cortex,” which controls the lips, tongue, jaw, and larynx as a person speaks. This gave them a map of which parts of the brain control which parts of the vocal tract.

They then applied a sophisticated new method called “state-space” analysis to observe the complex spatial and temporal patterns of neural activity in the speech sensorimotor cortex that play out as someone speaks.

This revealed a surprising sophistication in how the brain’s speech sensorimotor cortex works. They found that this cortical area has a hierarchical and cyclical structure that exerts a split-second, symphony-like control over the tongue, jaw, larynx, and lips.

The article, “Functional organization of human sensorimotor cortex for speech articulation,” is authored by Kristofer E. Bouchard, Nima Mesgarani, Keith Johnson, and Edward F. Chang. It appeared in the February 20, 2012, issue of the journal Nature and is at http:// dx.doi.org/10.1038/nature11911.

May 2013 San Francisco Medicine

33

Health Policy Superstar In Tribute to Philip R. Lee, MD Steve Heilig, MPH Can health policy be truly “evidencebased,” as health care itself is increasingly required to be? One would hope so. But con-

sider the Affordable Care Act—reporting on presumably the same law, our nation’s two leading newspapers tend to see the ACA as either the decline of Western civilization (The Wall Street Journal) or a hallmark of modern civil society (The New York Times). Where to turn for expert, detailed, fact-based perspectives?

At the recent fortieth anniversary dinner of the UCSF Philip R. Lee Institute for Health Policy Studies (IHPS) at San Francisco’s beautiful City Hall rotunda, a tablemate remarked, “If the big quake hit now and this place collapsed, American health care would have to start all over.”

Well, that might be at least partly true (the rotunda has been seismically updated, thankfully). The hall was packed with health policy “superstars.” The IHPS has been at the forefront of so many important health issues—health reform, access to care, cancer, tobacco, AIDS, professional education, medical economics . . . the list is too long. And while the recent and ongoing heated debates about “Obamacare” and the like are chronically politicized, those in the know look to the IHPS—and a very few other such sources—for data-based, historically astute, rigorously developed research and position papers. While it can be extremely frustrating to have ill-considered episodes such as the “death panel” remark of Sarah Palin derailing better end-of-life policy and care, these professionals of many disciplines keep cranking out their state-of-the-art work to (hopefully) guide health practice, education, and law.

But who is Philip R. Lee, beyond being UCSF chancellor emeritus, two-time United States assistant secretary of health (for Presidents Johnson and Clinton), and longtime Stanford medical professor and leader? Suffice it to say that he has been at the forefront of countless improvements in our nation’s health and is often referred to as a true living legend. Or, as longtime science editor and journalist David Perlman of the San Francisco Chronicle told me recently, “Phil Lee is one of the greatest people I ever encountered—even more so than all the Nobelists I got to interview or schmooze with!”

I’m a minor player in this realm, but that’s never seemed

34

San Francisco Medicine May 2013

to have mattered to Phil, and I’ve had the pleasure of knowing him for decades. As a lowly undergraduate studying microbiology, I found a book he coauthored titled Pills, Profits, and Politics and sent him a letter asking his opinion on the politics and economics of antibiotic overuse. I didn’t really expect to hear back, but he replied with a long and thoughtful letter—invaluable for my thesis. Much later I was honored to coauthor a piece on this topic with him, and a number of other essays and papers as well on topics such as medical education, health professionals’ participation in torture, environmental health, San Francisco’s universal health access plan, and more.

It was Lee’s name on these papers that gave them weight. And when I was cochairing a conference on environmental health at UCSF with Lee, one speaker, who is now a renowned senior health researcher and official, recalled, “The last time I was here to see Phil Lee I was terrified—I was an applicant to this medical school and was told the chancellor was going to interview me!” (This is somewhat akin to a Fortune 500 CEO interviewing applicants for internships.)

The guest speaker at the IHPS dinner was Harvard surgeon, bestselling author, and New Yorker contributor Atul Gawande, MD, who recalled that, as a young trainee during the Clinton administration, he would sit in on high-level health policy meetings with Phil Lee in attendance. “Somebody would bring up a proposal that sounded really good to me,” he said. “Phil would clear his throat and say, ‘Well, that’s been tried three times—didn’t work.’ I learned to just keep my mouth shut and listen and learn when he was around.”

Phil—as he is known to almost everybody who’s met him—was an SFMS member for decades, even though he recalls an AMA president labeling him a “communist” during a debate on the then-new Medicare program. He also recalls that when he was UCSF chancellor, then-Governor Ronald Reagan put heavy pressure on him to resign. Phil is writing his memoirs, which should fascinating. For now, he reflects that, over the past four decades, “The most important contribution of our institute has been the many people who have been trained there, considering what they’ve gone on to do.

We’ve made many important contributions in research, family planning, medical education, pharmacology practice and policy, the health professions, and more. In some areas we haven’t been quite as influential as we might have liked, but we’ve kept trying all along.”

On behalf of countless professionals and patients, thank goodness—and Phil—for that.

Steve Heilig, MPH, is assistant executive director for public health and education at the SFMS. www.sfms.org

“When I found out how much money I could save ($1,650) on the sponsored workers’ compensation program, I joined CMA. The savings paid for my membership and then some. Now I have access to everything CMA offers.”

Nicholas Thanos, M.D. CMA Member

D

id you know that CMA/San Francisco Medical Society members can save 5% on their workers’ compensation

insurance? And, they may save even more than that, up to 15%,

Please call a Client Advisor at 800-842-3761 today.

The process is simple and fast.

depending upon their group medical carrier.

It’s true. CMA/SFMS members receive a 5% discount on workers’ compensation insurance policies provided through Employers Compensation Insurance Company. This discount is available exclusively through Marsh/Seabury & Smith Insurance Program

Let us show you... how your membership in the CMA/

Management, the CMA/SFMS-sponsored broker and administrator.

San Francisco Medical Society

Rather than guess what your savings can be, take a moment to

Visit:

contact Marsh and let us show you how we can deliver a quality insurance program and exceptional savings to you.

Marsh is sponsored by:

can save you money.

www.CountyCMAMemberInsurance.com

Underwritten by:

63123/63159 (4/13) ©Seabury & Smith, Inc. 2013

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.CountyCMAMemberInsurance.com

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