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AN RANCISCO EDICINE S F M VOL.83 NO.4 May 2010

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Health Information Technology


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In This Issue

SAN FRANCISCO MEDICINE May 2010 Volume 83, Number 4 Health Information Technology

FEATURE ARTICLES

11 Editorial: How Much HITECH Is Good for You? Amy Berlin, MD 15 Hidden Costs, Hidden Savings Jonathan Kyle 17 Connecting San Francisco Arieh Rosenbaum, MD

18 Privacy in the Electronic Age Amy Berlin, MD

21 Handheld Technology Update Andrew Diamond, MD

22 Technology at Work for You Jordan Shlain, MD

MONTHLY COLUMNS

4 Membership Matters 5 Classified Ad 7 Executive Memo Mary Lou Licwinko, JD, MHSA 9 President’s Message Michael Rokeach, MD 24 Hospital News

25 In Memoriam Nancy Thomson, MD

OF INTEREST

26 Book Review: Still Searching for Hope in Haiti Steve Heilig, MPH

27 Health Policy Perspective: Is All Reform Local? Steve Heilig, MPH

30 In My Opinion: Lowering Health Care Costs Stephen Askin, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

www.sfms.org

May 2010 San Francisco Medicine 3


Membership Matters April 2010 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 83, Number 4 Guest Editor Amy Berlin, MD Managing Editor Amanda Denz Copy Editor Mary VanClay

Editorial Board Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes Clever

Ricki Pollycove

Gordon Fung

Stephen Walsh

Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term: Jan 2010-Dec 2012

Roger Eng

Gary L. Chan

Thomas H. Lee

Donald C. Kitt

Richard A. Podolin

Cynthia A. Point

Rodman S. Rogers

The 2010-2011 Membership Directory and Physician Desk Reference Watch your mailboxes! The 2010– 2011 Membership Directory and Physician Desk Reference is going out in middle to late May. One copy of the directory is sent free of charge to each active member as a membership benefit. If you do not receive your copy by early June, please contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org. Additional copies may be purchased at a reduced rate, which is also available to retired members. To purchase additional copies, contact Jonathan Kyle in the Membership Department at (415) 561-0850 extension 240 or jkyle@sfms.org.

Legislative Day Update

The 36th Annual CMA Legislative Leadership Conference was a tremendous success. This exciting day of political action included panels and presentations by CMA leadership and legislative experts as well as California government leaders, followed by an afternoon of county medi-

cal society members meeting with their legislators. Featured speakers included Richard Figueroa, Deputy Cabinet Secretary from Governor Schwarzenegger’s office; Seren Taylor, staff director, Senate Republican Fiscal Office; and Craig Cornett, budget director and chief fiscal advisor, Office of the Senate President Pro Tempore. The keynote speaker was Robert Hertzberg, speaker emeritus, California State Assembly and cochair, California Forward. In the afternoon SFMS members, joined by several UCSF residents, met with Assemblymember Fiona Ma, Senators Mark Leno and Leland Yee, and a representative from Assemblymember Tom Ammiano’s office. There are more reasons than ever for legislators to hear from you directly about the health care proposals being debated, as well as many other bills of critical importance to the practice of medicine. If you are interested in receiving a summary and current status of CMA-sponsored bills, subscribe to CMA’s Hot List. Go to http://cmanet.org/news/hotlist.asp and click on “subscribe now.”

Adam Rosenblatt Lily M. Tan

Term: Jan 2008-Dec 2010

Shannon Udovic-

Jennifer H. Do

Constant

Shieva C. Khayam-Bashi

Joseph Woo

William A. Miller Jeffrey Newman

Term: Jan 2009-Dec 2011

Thomas J. Peitz

Jeffrey Beane

Daniel M. Raybin

Andrew F. Calman

Michael H. Siu

Lawrence Cheung CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

SFMS members meet with Senator Leland Yee to discuss legislation affecting California physicians and their patients 4 San Francisco Medicine May 2010

www.sfms.org


Tell Us: Why I’m a Member SFMS is launching a member-driven promotional campaign and needs your help. The campaign, entitled “Why I’m a Member,” will draw exclusively upon quotes from members about their experiences with SFMS. To help get this campaign off the ground, we are asking you to share memorable moments, stories, and anecdotes that exemplify why you are a member of SFMS. Please keep submissions under 200 words. E-mail submissions or questions to Jonathan Kyle at jkyle@sfms.org. We thank you for your participation and look forward to hearing from you.

Stay Informed and Help SFMS Go Green!

The San Francisco Medical Society wants to make sure that you have important information in a timely fashion. If you’ve been receiving faxes, consider changing to e-mail delivery and save paper and toner; additionally, receiving communications by e-mail enables you to click on links to receive further information on important issues.

Make sure SFMS has your e-mail address (SFMS does not share its members’ e-mail addresses). You can add this information to your membership profile by going to the Member Login section of the website at www.sfms.org or by contacting the Membership Department at (415) 561-0850 extension 268 or e-mailing tporter@sfms.org.

Workshop: Clearing the Fog Between Ethics and Law

The Program in Medicine & Human Values at California Pacific Medical Center presents to following workshop: Clearing the Fog Between Ethics and Law 2010 Summer Workshop in Clinical Ethics June 12, 2010, 8:30 a.m. to 3:30 p.m. Fromm Institute for Lifelong Learning, University of San Francisco This annual one-day workshop provides an intensive, interactive introduction to the analysis of ethical problems in clinical care. The workshop is directed to physicians, nurses, social workers, chaplains, attorneys, teachers and other professionals involved in the care of patients or the education of providers. There

will be 5.0 continuing education credits for Medicine, Nursing, Social Work and Chaplaincy. Tuition is $145.00. For more information, or to register for the seminar, please email ethics@sutterhealth. org or www.cpmc.org/services/ethics/ seminar.html.

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Independent But Not Alone.

James Yoss, M.D. Hill Physicians provider since 1994. Uses Hill inSite and RelayHealth services for ePrescribing, eReferrals and secure online communications with patients.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Get more information about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.


Executive Memo Mary Lou Licwinko, JD, MHSA

SFMS Launches Health Information Exchange

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ver the last nine months, SFMS President Dr. Michael Rokeach, other members of the San Francisco Medical Society (SFMS), and I have been working closely with representatives of the major health entities in San Francisco to launch a health information exchange. The San Francisco Health Information Exchange (SFHEX) will be designed to link clinical data among providers in San Francisco, with the goal of improving patient care. In 2009, when the first federal stimulus money was announced for the implementation of health information exchanges and extension centers, SFMS was approached to become a full participant in planning for the development of the SFHEX. One significant contribution SFMS has been able to make to the process is to use the SFMS Community Service Foundation (SFMS CSF) to provide a home for the SFHEX. Because of its 501(c)(3) status, the SFMS CSF provides an immediate vehicle for the receipt of grants to help fund the development of the SFHEX. I am delighted to report that the SFHEX has seated nearly 100 percent of the health care groups identified to serve on its Governing Committee. These organizations are:

Chinese Hospital Association Catholic Healthcare West Sutter Health San Francisco Kaiser Permanente San Francisco Community Clinic Consortium Brown and Toland IPA Hill Physicians IPA San Francisco City and County Department of Public Health San Francisco Mayor’s office An at-large independent physician appointed by the SFMS

The bylaws governing the SFHEX also allow for the inclusion on the Governing Committee of a health care consumer and an alternative medicine provider, and the committee hopes to choose these individuals soon. SFMS members Drs. Arieh Rosenbaum and Amy Berlin serve as chair and cochair of the committee. You will note that Dr. Berlin is the guest editor for this issue of San Francisco Medicine and Dr. Rosenbaum has authored an article on the genesis of the SFHEX on page 17 of this issue.

Visit the SFMS Blog! • Stay up to date on local news and events • Get involved in the discussion about health care through the commenting feature • Read entries by guest bloggers from your medical community • See photos of SFMS events

Our blog is updated several times per week with the latest local news in health care

http://sfmedicalsociety.wordpress.com/ Follow us on twitter or become a fan on facebook to be notified when new entries are posted on the blog! Visit www.sfms.org to learn more and for links to our profiles.

www.sfms.org

May 2010 San Francisco Medicine 7


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President’s Message Michael Rokeach, MD

Medical Information and Technology

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his issue of San Francisco Medicine addresses one of the timeliest and most important issues facing medical care providers this year—and likely for the next several years. After changes in how patients will access providers and how providers will be compensated for services, how we collect and record medical information is front and center in our world. Advances in technology now allow us to move away from paper and pen. We can enter history and physical exams directly into a computer rather than handwrite them. If for no other reason than that others will not have to deal with legibility issues (as well as Joint Commission and CMS requirements), patients will be safer. Our medical society is in the midst of creating a means of exchanging medical information on any patient with a medical encounter in San Francisco. Mary Lou Licwinko and Arieh Rosenbaum describe the SFMS role in developing this important tool. Our efforts, plus those of all providers within this community, are working feverishly to create a HEX, or health information exchange. This will undoubtedly reduce overuse of resources, provide more accurate clinical data, and promote better care for our patients. It does, however, require that providers maintain their patient’s information in an electronic format. Kaiser SF has already installed a complete EHR that allows the exchange of patient information among all of their physicians. What happens if one of your patients ends up in the Kaiser or San Francisco General emergency department, where no record of that patient exists? In the near future we expect those physicians will have access health records from the patient’s medical “home.” Knowing that this patient had a normal CT scan or MRI just last week will undoubtedly go a long way in avoiding overtesting and duplication of procedures. The federal government has made the use of electronic health records a priority. CMS will provide significant financial support to those physicians who implement office-based electronic systems, to the tune of as much as $65,000 for those with large Medicaid patient populations. And if physicians choose not to upgrade to an electronic system with “meaningful use,” CMS will start penalizing them by lowering their reimbursements. Here we see both the carrot and the stick. This issue of SFM helps physicians stay informed about what’s happening in this arena. Andrew Diamond writes about www.sfms.org

the use of handheld devices in medical practice. In the not-toodistant future, there will be an array of technological gadgets and devices that will facilitate more efficient and—more important—safer patient care. We include helpful information regarding regulations and programs created by the HITECH Act, the federal government’s legislated effort to promote EHR implementation. This bill was part of the ARRA, or American Reinvestment and Recovery Act, which supports recovery from our recent financial crisis. Who wouldn’t support such efforts, especially considering where taxpayers’ hard-earned dollars were spent over the past decade. And finally, a personal note: For the past six years, I have been fortunate to have an electronic medical record system in my practice. In our emergency department, we use a system designed by an emergency physician specifically for our type of practice. It includes all the documentation by both nurses and physicians. I complete all of my patient encounter records in an electronic format. The signature is electronic, eliminating the need to go to medical records to sign charts. Legibility is never an issue (a new CMS rule). Previous records are immediately retrievable. We use preprinted discharge instructions, and we print prescriptions from a formulary list. And a major benefit is the ability to chart entries remotely on the Internet. Given a choice, I would never retreat to paper and pen again. To some, embracing electronic technology in their medical practices will be challenging. To the younger physicians, who grew up in the computer world, it will be second nature. But most of all, it will be good for our patients. Please enjoy this terrific issue of SFM—then just point and click!

May 2010 San Francisco Medicine 9


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Editorial Amy Berlin, MD

How Much HITECH Is Good For You?

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ith all I see coming down the pike, it seems overwhelming at times. . . . I have looked at the meaningful use criteria, and my first thought was there is no way I’m even going to try. For $44,000 or not, it really doesn’t seem worth it.” “I figure it pretty much pays for itself. If you’re somewhere where good staff and square footage are cheap and plentiful, the equation might change. If you like computers, like me, the equation might change. If you hate computers, the equation certainly changes.” “The day is one of scrolling and clicking. No time to look up from the screen. Present and future.” You’ve just been eavesdropping on an online conversation hosted at SERMO (www.sermo.com), a physician-only social networking website. The topic, electronic health records (EHRs) and efficiency. The opinions, varied. The emotions, heated. Why all the energy? If you missed the news flash in 2009— or if you caught wind of it and went running the other way (a not so unpredictable response if you are anything short of a total techie enthusiast)—consider this issue of San Francisco Medicine your roadmap to the HITECH Act and all it means for your practice. For a brief history and glimpse of the future of HITECH, see the timeline on page 13. Health information technology (HIT) reform has long been a bipartisan no-brainer. After all, who would dispute the value of accessible, up-to-date, and comprehensive information about our patients wherever and whenever we need it? For those of us who remember residency as a sea of index cards scribbled with lab values and medication lists, or for those of us whose daily practice is encumbered by looking for lost charts, lost discharge summaries, or dubious “medication reconciliations,” information-about-my-patients-at-my-fingertips doesn’t sound half bad. Leading the Office of the National Coordinator for Health Information Technology’s (ONC) charge to realize this vision is Dr. David Blumenthal, who, in a November 12, 2009, online column at the ONC website (http://healthit.hhs.gov/portal/server. pt?open=512&objID=1406&parentname=CommunityPage&pa rentid=1&mode=2&in_hi_userid=10741&cached=true) wrote that a “key premise” of the HITECH Act is “information should follow the patient, and artificial obstacles—technical, business www.sfms.org

related, bureaucratic—should not get in the way.” Those obstacles are extensive, and they are part of why the HITECH Act is being met with a range of responses, from excitement at the prospect of overcoming them to extreme skepticism. It is also why the HITECH funds will seek to pave the information highway from a variety of angles (visit www.sfms.org/HITECH to see a diagram outlining an overview of the numerous initiatives and pilot programs funded by HITECH ). In a fascinating article titled “Testing, Testing” (http://www. newyorker.com/reporting/2009/12/14/091214fa_fact_gawande), published in the December 14, 2009, issue of The New Yorker, Atul Gawande (author of the best-selling The Checklist Manifesto) drew an interesting historical parallel between the thrust of HITECH and a turn-of-the-last-century government program to overhaul agriculture. As he reminds us, food production in the early twentieth century was strangling the economy. Farmers, suspicious of mechanical innovations in farming, engaged in shortsighted crop production solutions that had disastrous results for the economy. In an effort to encourage farmers to farm differently, the USDA launched a pilot program of “extension agents,” charged with the mission of embedding themselves in farming communities across the country to gain the trust of local farmers with whom they could—and eventually did—problem-solve on the ground. The story is an inspiring read of an entire industry that revitalized itself—not through market forces or fiat but through graduated, governmentenabled changes. The implication is that we should not underestimate the potential power of pilot programs such as HITECH-Act-funded RECs or Beacon Communities to evolve our health care system. And while I maintain optimistic expectations for these programs, I do think it is problematic to compare the USDA program— launched at a time in history when no country had been able to solve the problem of efficient food production for its people—to the present day, where we enjoy a dubious status as the only industrialized nation that loses thousands of lives and sees millions going bankrupt annually for lack of adequate health care. What does all this mean for the physician on the front lines, practicing, as most physicians in this country do, in solo- and small-group practices? While the national debate on health reContinued on the following page . . . May 2010 San Francisco Medicine 11


Continued from the previous page . . . form (or health insurance reform, depending on your vantage point) continues, individual physicians need to consider how much change they are willing to embrace in their own practices. The fact that the average physician practice is not capturing electronic information in a coded format, let alone using that information to track patient outcomes and report quality data, means that physicians seeking to meet the requirements of meaningful use have no small project of practice reform on their hands. For some practices, larger organizations—the hospitals or IPAs with whom they are affiliated—will determine for them whether or not they go electronic. But for many, those affiliations alone are unlikely to offset the labor-intensive process of work-flow redesign that is required of incorporating any new technology into an environment as complicated in operations as a typical physician practice. Anyone who has ever perused an EHR vendor’s promotional materials has likely come across the phrase ROI (return on investment). As noted by the above-quoted SERMO users, return on investment for electronic health records rarely comes in the form of hypertrophied bank accounts. Most satisfied EHR users report more effective use of their time and better-informed clinical decisions from having intelligible patient and clinical information show up at the same time in the same place. So not only will ROI for many feel initially intangible, given the drops in productivity required by physician practices as they shift their work flows and learn new systems, but it will also come slowly. This is because EHRs are not plug-and-play technologies but require what the authors of a still-very-relevant 2003 California Healthcare Foundation publication entitled Electronic Medical Records: Lessons from Small Physician Practices (http://www.chcf. org/documents/healthit/EMRLessonsSmallPhyscianPractices. pdf) describe as complementary changes. These include “customizing electronic forms (templates) that [come] with EMR software, arranging extra support for technical problems . . . [and] rearranging processes in the office as a whole.” This is why the HITECH RECs and LECs, medicine’s modern-day IT field agents, will be a crucial resource for many of us. The health informatics literature is replete with lessons learned from EHR implementations—successful and failed. Not surprisingly, just as complementary changes are key to small practices, larger organizations risk painfully dismal results if they do not devote significant resources to work flow and operations redesign. What is becoming additionally apparent is that integrated health care delivery organizations seem to have an advantage on ROI from EHRs. For the Geisingers, Kaisers, and Intermountain Healthcares, health care information technology functions as a tool to advance organization-wide strategic initiatives around quality, population health, and patient safety. As integrated delivery systems, they provide a conduit for flow of health care information (across levels of care, among providers, between patient and doctor via patient portals) that ensures that the trajectory from clinical information review to clinical

12 San Francisco Medicine May 2010

decision making is enabled and seamless. Contrast this with the scenario of an independent physician who determines, based on her patient’s presentation and the data in her EHR, that her patient needs a referral to a specialist but who must help her patient obtain insurance authorization (via a time-consuming manual process) for this referral before the patient can proceed to the next stage of care. In this next chapter in the HITECH Act timeline, we will begin to answer the question of how information technology can make a fragmented health care system feel more cohesive. While I am a health care IT enthusiast, I think that the organizations— or in this case, systems—that deploy information technology need to be healthy themselves in order for the benefits of IT to be realized. This does not mean that HITECH is an all-or-none proposition. There are many ways that health care organizations, small and large, and the people they care for stand to benefit from the provisions of HITECH. But key inequities that derive from the way health care is currently structured and financed in most of the country will not be solved by modernization of information flow alone. My very strong personal bias is that the story of EHR ROI in integrated delivery systems is yet another (but certainly not the most compelling) argument for the need for universal health care with a single payer model. Fragmented systems simply cannot provide the same sort of balance of individual- and population-based health that integrated systems do. There is no information technology that I know of that can correct for our appalling race- and class-based variances in health outcomes. In the meantime, as we roll up our sleeves to address this small, but not insignificant, piece of a broken system, we will be evolving the practice of medicine, learning and growing as we go. Amy Berlin, MD, helps health care organizations and private practices break free from IT twilight zones— without compromising efficiency. She remains clinically active in her psychiatry private practice and on the volunteer faculty of the UCSF Department of Psychiatry. Visit her at www.amyberlinmd.com or amy@amyberlinmd.com.

Join the conversation on HITECH at the SFMS blog • Share your thoughts, questions, and experiences about EHRs and HITECH • View a reprint of this editorial, complete with hyperlinks • Browse SFMS’ complete list of EHR Implementation Pearls and Resources

http://sfmedicalsociety.wordpress.com/

www.sfms.org


HITECH Timeline

A 2004 The position of National Coordinator of Health Information Technology, (1) created through Executive Order by President Bush.

February 2009 President Obama signs the Health Information Technology for Economic and Clinical Health Act (HITECH Act) as part

of the American Reinvestment and Recovery Act. HITECH codifies and funds the Office of the National Coordinator for Health Information Technology (ONC), whose mission is to “[promote] development of a nationwide health care information technology (HIT) infrastructure that allows for electronic use and exchange of information that insures secure and protected patient health information.” The HITECH Act creates a system of incentive payments and infrastructure (visit www.sfms.org/HITECH to see an overview of this infrastructure) for Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) providers, including hospitals and physicians, community health centers, clinical data repositories, and public health departments that adopt and use health information technology. It provides for creation of standards for meaningful use (MU) of HITECH. These standards are pending final definition and must be demonstrated by eligible physicians and health care organizations to qualify for incentive payments. Finally, HITECH strengthens current HIPAA rules to provide for enhanced security and privacy of protected health information (PHI).

December 30, 2009 The ONC submits for 60-day period of public comment proposed definitions of MU of Electronic Health Records

(EHRs) and proposed rules for standards for certification of EHR technology (2). The first rule describes the ways in which eligible physicians and hospitals are expected to use EHRs; the second rule describes a framework for certifying EHR products that possess all the necessary functionalities to enable MU. Per the HITECH Act, in order to qualify for incentive payments, eligible physicians and hospitals will need to demonstrate increasingly rigorous definitions of MU in the coming years. According to the ONC, the first level of MU, Stage 1, which will begin in 2011, “includes, but is not limited to, electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information to help coordinate care, and initiating the reporting of clinical quality measures and public health information.”

March 15, 2010 Period of public comment on proposed rules for MU of EHRs and EHR technology certification closes. As of press time, these rules have not been finalized. October 2010 Qualifying hospitals can begin to receive incentive payments.

2011 Qualifying physicians (and other health care providers, such as dentists, podiatrists, optometrists, and chiropractors) may begin to receive incentive payments. Physicians may choose to pursue incentive payments through Medicare or Medicaid, but not through both programs. Each year through 2016, the maximum incentive payment will decrease. Find incentive payment timetables at the Centers for Medicare and Medicaid Services (CMS) website (3). As of press time, the process for obtaining incentive payment has not been determined. 2013 Stage 2 requirements for MU take effect. These requirements, pending final definition, will be designed to encourage the use of HIT to enhance computerized provider order entry, transitions in care, electronic transmission of diagnostic test results, and research. 2015 Stage 3 requirements for MU take effect. These requirements, pending final definition, will be designed to promote improvements to quality and safety, use of clinical decision support, and gathering of population health data. (4) 2015 Physicians who have not demonstrated MU and who bill Medicare or Medicaid will be reimbursed at lower rates. According to the

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CMS, “The Medicare fee schedule amount for professional services provided by [a physician] who [is] not a meaningful EHR user for the year [will] be reduced by 1 percent in 2015, by 2 percent in 2016, by 3 percent for 2017, and by between 3 to 5 percent in subsequent years.” 2016 Last year for qualifying physicians to receive incentive payments.

(1) For more on the ONC, go to http://healthit.hhs.gov/portal/server.pt?open=512&objID=1200&mode=2.

(2) From http://healthit.hhs.gov/portal/server.pt?open=512&objID=1496&parentname=CommunityPage&parentid=3&mode=2&in_hi_userid=10741&cached=true. (3) Medicare incentive payment information can be found at www.cms.hhs.gov.

(4) From http://www.himss.org/ASP/ContentRedirector.asp?ContentID=72842&type=HIMSSNewsItem.


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Health Information Technology

Hidden Costs, Hidden Savings The Inside Story on Switching to Electronic Health Records

Jonathan Kyle

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hen the American Recovery and Reinvestment Act was passed in 2009, billions of dollars were allocated for improvements in health information technology. And while some large medical groups like Kaiser, who already have fully integrated electronic health record (EHR) systems, are well positioned to receive federal subsidies, many solo and small-group medical practices believe that the costs of such implementations far outweigh the financial incentives being offered. As a result, a relatively small percentage of these practices have gone electronic.

A Soloist’s Perspective

San Francisco-based physician Paul Abramson went electronic with his solo family-practice group about a year and a half ago. And while he is happy with his decision to do so, Abramson cautions against rushing into anything solely because of the incentives in the new legislation. “In a sense, I think it’s a lot of hype about nothing,” he says. “It’s I think $44,000 over five years that you can get per doctor,” Abramson says. “If you really think about it in terms of the volume of business that a busy medical practice does, it’s a relatively small amount of money. If you do a very low-cost electronic health record, it might pay for that and all the staff time it’ll take to implement it, but it doesn’t make it worth it to implement something that will make your life more difficult.” Abramson uses an EHR system called Amazing Charts, which costs a one-time fee of just under $1,000 per doctor. He also pays around $40 per month for unlimited system upgrades and technical www.sfms.org

support, which he admits he has yet to use. “It’s not just reasonable, it’s cheap,” Abramson says of the software. “It’s very clunky and not very exciting, but it does the basic functions, and that’s what I wanted, was to get things electronic as sort of a placeholder until the perfect product comes along.” In addition to the software being clunky, Abramson acknowledges some of its other limitations, such as the fact that it doesn’t automatically integrate with his Outlook calendar. But Abramson has been able to make it work, largely because of his tech savvy and the fact that only he and his office manager use the software, both of which he considers to be key factors of his setup’s success. Abramson, who has an engineering background and does some technology consulting on the side, hosts the software on his own server and has created custom templates for documenting the various types of patient visits. This has virtually eliminated any need for outside IT support. “Even the better, bigger systems like Allscripts, that a lot of doctors in San Francisco use because Brown and Toland offers it for cheap, I think it doesn’t work that well and it slows them down,” Abramson says. Herein lies a potentially major pitfall for doctors making the transition to an EHR system. For those who either can’t type fast or aren’t especially comfortable with computers, it often requires that they or their staff spend time typing up charts after each patient’s appointment. Even with the use of voicerecognition software, the degree to which this can cut down on an office’s efficiency, and thus its earning power, will quickly nullify any benefits from the stimulus

money it receives, Abramson says. Another major concern facing doctors with regards to EHR systems is the fact that the current market is oversaturated with vendors, and most of products available are incompatible with one another. “There is no interoperability right now,” says Abramson. “Your data is in what they call silos. Kaiser is a silo, UCSF is a silo, CPMC is a silo, and my practice is a silo.” Abramson is on the governing committee for the San Francisco Health Exchange (SFHEX), where he serves as the representative for independent physicians. He explains that one of the primary goals behind the SFHEX is to help link these “silos” and facilitate the exchange of health information in the city. “Ideally, all the big players would want good care for everyone anywhere, but there may be business interests that trump that,” he says. “Unless everyone plays, it’s not going to work very well.” Further complicating EHR implementations is the fact that doctors are still unclear about what exactly they need to do in order to meet federal requirements and make themselves eligible for stimulus money. “The exact requirements haven’t really been finalized yet, as I understand it, so it’s hard to know which products will qualify,” Abramson says. “There’s something called ‘meaningful use,’ [where] you have to have a product that you use for your practice that will provide health records, provide patients access to their own data, and it has to be interoperable with other health care entities.” Abramson admits he hasn’t looked into it that carefully, partly because he’s Continued on the following page . . . May 2010 San Francisco Medicine 15


Continued from the previous page . . . not sure he’ll even qualify. “You have to do a fair amount of Medicare business to get the money,” Abramson says. “It’s paid as a percentage bonus on top of your Medicare payments. So unless you’re billing enough Medicare, you can’t get it.” Because Medicare patients only comprise about ten percent of his business, Abramson isn’t getting his hopes up. Another unappealing element of transitioning to an EHR system is the painstaking process of converting and reorganizing what can be many years’ worth of paper charts into electronic files. “It’s very daunting because you have to scan all your previous charts [and] you have to somehow learn the new system,” Abramson says. “Everybody has heard horror stories of doctors winding up with products that cost them lots of money, don’t work very well, and end up being extremely disruptive to their practice.” Part of what made the transition relatively seamless for Abramson was the fact that he was only six months into his practice when he implemented his EHR system, and he wasn’t burdened with a library of paper files. A concern some patients have with regards to EHR systems is how their doctor’s bedside manner will be affected. Abramson says most of his patients are comfortable with how he incorporates the computer into the examination process. He does note, however, that his younger patients are the most comfortable with it, while older patients still have some reservations. Abramson believes the ability to touch-type well goes a long way in making patients more comfortable because it allows doctors to maintain eye contact during the exam. He is also conscious about positioning the monitor in a way that allows patients to read their own record so they feel more involved and can be assured that their exam is documented accurately. “When I type things in, I’m more aware that it might be read by somebody, whereas if I’m scribbling on a piece of paper I’m not always as complete,” Abramson says. “It creates more legible medical records.” He cautions, though,

16 San Francisco Medicine May 2010

that for a doctor who can’t touch-type, it could potentially become a distraction and an annoyance to patients. As Abramson sees it, there are several crucial components to any successful EHR implementation. The first is a willingness to change practice methodology. “Many practices have been stuck in [a] dysfunctional system for a while, and this is just the catalyst that brings up that change,” he says. Equally important, he believes, is having an exit path and determining beforehand what the ramifications would be if an implementation was unsuccessful and the practice had to switch to a different product. Finally, Abramson emphasizes the importance of having the right perspective on the process. “You’re investing a lot of time and money, but it’s really in retooling your practice in a way that you’re going to be happier and go electronic,” Abramson says. “So you can view the investment as not just paying for technology, but paying to make your practice better.”

A Small-Group Perspective

Before relocating to San Francisco in 2007, cardiologist Peter Curran was part of a small practice in Napa that had recently implemented an EHR system. He says that the cost of his former practice’s implementation was nearly $300,000. Though Curran says the practice is far from seeing considerable financial returns on its investment, he believes there have been some benefits. “They’re using it effectively for billing, scheduling, some archiving, and partially using it for the electronic medical record, so it wasn’t a total disappointment,” he says. While working at the practice in Napa, Curran used the EHR system in several different ways. Initially, he used the portable tablet computers the office had during exams; however, he quickly abandoned them because he found their wireless connections to be shoddy and he felt they detracted from the patientdoctor encounter. Eventually Curran found a routine that worked for him. “I would bring up the information before the patient came in, to refresh my memory,” he says. “I might

even set up a template for the kind of visit it was going to be. I would go and see the patient separately, then after the appointment come back into my office on my PC and finish up the electronic note. It’s not the most efficient [way], but I got quick enough where I wasn’t letting it stack up to the end of the day.” Given the current economy and insurance model, remaining economically viable is first and foremost on the minds of most solo and small-group doctors. This is one reason Curran believes EHRs are not even on some practices’ radar. “Obviously we want to keep cost as low as possible, but I think it’s more specific than that,” Curran says. “I think you need to know how the system will be used specifically for your type of practice before you buy it.” Patient portals are a feature that Curran believes are becoming increasingly appealing, particularly to younger patients. Because cardiology practices like Curran’s tend to serve primarily older patients, many of whom are less computer savvy, he questions whether his patients would even use them. “In my practice I could buy that and I don’t think more than a handful would want to or know how to access the patient portal,” he says. “I think there’s a generational gap, and if you go and buy into all the extra bells and whistles and you don’t use [them], it just becomes an added expense.” Curran has begun looking into some of the free Web-based solutions for creating and storing electronic medical records, such as Google Health and Microsoft Vault. He thinks these options could make going electronic more financially accessible to solo and small-practice doctors. “The data I’ve looked at seems to suggest that the only practice groups that are already saving money or seeing return on investment are the large practice groups,” Curran says. Unlike most solo and small practices, something these groups have working in their favor is deeper pockets, allowing them to invest in more comprehensive technical support and training. “I have not found anywhere where it has Continued on page 20 . . . www.sfms.org


Health Information Technology

Connecting San Francisco The San Francisco Health Information Exchange

Arieh Rosenbaum, MD

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our patient arrives for a ten-minute appointment and tells you he was discharged yesterday from a hospital across town. At discharge, he was instructed to follow up with his PCP immediately. He believes he was hospitalized for “an infection” but can provide no further details. He has not brought any paperwork or any of his new prescriptions. You were not aware that he had been in the hospital. The San Francisco Health Information Exchange (SFHEX) was born of a shared vision: the secure electronic exchange of clinical data among health care providers with the goal of improving patient care in San Francisco. Today, exchange of clinical information in San Francisco is highly variable in terms of its timeliness, reliability, and effectiveness. Most providers and organizations continue to use telephones, faxes, and the U.S. mail for clinical collaboration. New information from outside sources is frequently unavailable to providers at the point of care, and if it is, the information is often incomplete, illegible, or both. The idea of a unified patient record that aggregates all available clinical data when it is needed has before now been just a dream, one that the SFHEX hopes to finally allow the city to realize. The recent thrust for a health information exchange (HIE) in San Francisco has its genesis in the ARRA bill signed into law by President Obama on February 17, 2009. Contained within that bill was the HITECH Act, now well known in the medical community for the funds it directs toward electronic health record (EHR) implementation. Also allocated within HITECH was nearly $600 million in grants designated specifically for HIE. EHR and HIE were definitively linked through the “meaningful use” proviwww.sfms.org

sions of the legislated incentive package. Within California, HITECH stimulated renewed activity and interest in HIE. One notable outcome was the formation of the California eHealth Collaborative (CAeHC, a nonprofit group of active stakeholders that encouraged grassroots collaboration on health information technology around the state. CAeHC organized a series of “HIE town halls” designed to begin organizing local communities interested in such a project. The San Francisco town hall was held on May 28, 2009; the meeting was packed with enthusiastic local stakeholders. From there, the SFHEX was off and running. The first meeting of the SFHEX committee took place on August 20, 2009. By the second meeting, all major health care organizations in the city were informally represented. Over the next two months, the committee crafted a basic vision for the health information exchange, in conjunction with a simple governance model and a summary list of data sharing priorities. During this same period, the committee worked closely with the San Francisco Medical Society leadership to make the SFHEX part of the Medical Society’s Community Service Foundation. The Foundation bylaw changes incorporating the SFHEX were approved on December 7, 2009. The partnership gained the SFHEX immediate 501(c)(3) status, a notable accomplishment. Such IRS status is considered extremely important for a viable HIE and can often take years to acquire. By late December, it was time to reach out beyond the conference room for formal endorsement of the SFHEX. A small group of volunteers from the original committee authored a presentation that detailed the case for a new health information exchange

in San Francisco. This was presented to the San Francisco Hospital Council in early February. The Hospital Council members were asked to support the SFHEX through the formal appointment of individual representatives to be seated on the new SFHEX Governing Committee. The first meeting of the SFHEX Governing Committee took place on March 17, 2010, with all major health care organizations in San Francisco at the table. Also in attendance were two representatives from the San Francisco Medical Society (cochairs) and one at-large independent physician. The Governing Committee has since had one additional meeting and has put together a detailed collective vision for what the future health information exchange might look like. We now begin the challenging process of outlining business and technology plans, as well as pursuing grants and general funding. We hope to launch the HIE sometime in 2011. The summary goal of the SFHEX reflects a solution to the problem outlined in the clinical vignette above; that is, to provide immediate and universal provider access to critical clinical data at the point of care. We expect multiple related benefits from the HIE, including reduced duplicative testing, a decline in citywide resources devoted to clinical data gathering, and a contribution to provider eligibility for stimulus funds under “meaningful use.” Ultimately, the true value of the SFHEX will be realized in the delivery of higher quality care to the citizens of San Francisco. Dr. Rosenbaum is co chair of the San Francisco Health Information Exchange and is a hospitalist with Pacific Inpatient Medical Group, a physician-owned group of approximately 50 hospitalists, affiliated with CPMC. May 2010 San Francisco Medicine 17


Health Information Technology

Privacy in the Electronic Age An Interview with San Francisco Department of Public Health’s Dave Counter on HITECH and HIPPA

Amy Berlin, MD

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or many physicians who have been practicing with paper charts and limited information technology in their practices for many years, their first response to the idea of an electronic health record (EHR) is, “How do I know that an EHR will keep my patients’ information confidential?” To learn more about information security in the era of EHRs, San Francisco Medical Society (SFMS) interviewed Dave Counter, chief information officer (CIO) and HIPAA security officer for the San Francisco Department of Public Health (SFDPH). SFM: Can you explain what a HIPAA security officer does?

Counter: I often encounter the confusion between the privacy and security dimensions of HIPAA. Everyone thinks that HIPAA is all about security, but, in fact, HIPAA is more like 80 percent about privacy and 20 percent about security. What we have done at the SFDPH—and this is true about most large health care organizations—is we have a privacy officer as well as a security officer. The easiest way to explain the difference is that privacy, where most of the regulations really lie and where the emphasis of the expanded HIPAA regulations is based, has to do with a set of regulations governing disclosure and the right to see protected health information (PHI). It’s not too different from the types of regulations that are currently governing [electronic and nonelectronic] medical records. So HIPAA security really has to deal with the electronic aspects of information gathering, information storage, and, most

19 San Francisco Medicine May 2010 18 San Francisco Medicine May

particularly, access and transmission of electronic PHI. There is a very specific set of regulations in HIPAA that have to do with a couple of broad areas: having in place the correct policies for electronic information, physical safeguards of the actual environment, and technical safeguards [to make] sure that we have the correct protocols for authentication and access to electronic files. The HITECH Act expanded HIPAA. How?

Differentiation between the HIPAA privacy piece and the HIPAA security piece is important to understand, because if you look at the expanded regulations it’s really about the required notification of information breaches, the minimum amount of information that someone is able to see when they request information, and the extension of HIPAA to business associates. Business associates are now required to maintain the same administrative, physical, and technical safeguard requirements as providers, as well as maintain HIPAA-compliant policies, procedures, and documentation. This means they must also comply with the same breach notification regulations as the primary provider. So the expanded HIPAA regulations under ARRA really don’t change the security aspects all that much. We aren’t really required to do too much differently, except be able to provide the patient with an electronic copy of their records if they want an electronic copy. But an electronic copy can actually be a printed report, as long as it comes from an electronic file. And I think the intention there is that if

you keep [patients’] information in electronic format, make sure you have a way to get it to them if they ask for it. Other than that, everything else—expanded penalties, breach notification, and so on—I think that falls under the privacy component of HIPAA. The whole emphasis of ARRA (American Recovery and Reinvestment Act) is in large part the foundation of a broader concept that emphasizes ease of sharing information among providers. It is very difficult to share nonelectronic information, and, as you know, folks fax things and mail things, and of course e-mail as well. The ultimate incarnation of shared information is EHRs that are designed to be able to do just that. The HIPAA regulations in terms of disclosures and penalties apply to the nonelectronic environment as well as to the electronic environment. So if you were to look at some of the basic regulations governing this, if you had a breach of PHI, that could easily be a provider leaving a file in the car, which gets broken into; or you drop a file and all the paper goes flying all over the place; or you fax PHI and the fax gets into the wrong hands. In other words, the kinds of breaches that require notification occur in the nonelectronic domain and as well as in the electronic domain. I think the biggest trend that needs to be addressed is the use of mobile devices and the use of electronic mail and how that gets defined as secure or not. So, for instance, with electronic mail: Generally speaking, the way that the HIPAA regulations are written is that if you are on a secure organizational network, it isn’t necessary to encrypt the information in an electronic message. An example would www.sfms.org


be if you are part of the DPH network, where there are firewalls preventing access from outside the network. Because our network is secure, if an internal e-mail is sent from one provider on the network to another, no additional security safeguards need to be taken. The minute you don’t have that—say you’re communicating with someone outside of the network—then a whole set of safeguards, such as encryption of the data on the mobile devices, becomes important. I think that’s one of the challenges [of keeping up with HIPAA]. If people want to use their PDAs and their external emails, they need to make sure they’re aware of who they’re interacting with. If you are outside of a protected environment, you have to take some safeguards. I think that is one place where the expanded HIPAA requirements are really important. Can you define what you mean by “encrypt”?

When you encrypt data, there is software that takes a file, the way that it is stored in the computer, and applies certain algorithms to it. It kind of codes it so it cannot be read. So when data is encrypted, even though it might be intercepted by someone in the process of transmission, it is unreadable because the person who is looking at it does not have the software key to sort it out so that it can be read in its original format. Some argue that paper charts are not without risk—risk of loss, damage by water or fire, or theft, for example—but that users of paper charts are so used to these risks that they don’t notice them anymore. How, in your mind, do the information security risks of paper charting and electronic charting balance out?

If you have an EHR, then you are able to do a couple of things that you are not able to do [with a paper chart]. Since you are now in an electronic environment, from an infrastructure standpoint, you can lock devices, meaning network devices and computing devices can be

www.sfms.org www.sfms.org

locked down and secured. Everything can be password-protected and the data in electronic format can be encrypted. For transmission of data, SSL (secure sockets layer) technology enables you to get a point-to-point connection between the sender and recipient of the information in a way that is not immediately transparent to the Internet. And that puts the providers in a much better position from a security standpoint than does faxing it or mailing it. If there is a breach, [HIPAA requires] notification to patients that their PHI has been compromised. In the paper world, it is much harder to know if that has occurred. If someone picks up a chart and rifles through it, you cannot easily detect this. With electronic information, generally speaking, [EHR] vendors provide access logs so you can see what files were accessed, when, and by whom. Different levels of access to different parts of an EHR can be set up according to user role, based on a “need to know” basis. Since the new meaningful-use requirements are designed to facilitate sharing of information, the regulators want to make sure that the right people are getting access to the information. You can do a side-by-side analysis of the pros and cons of protecting information in an electronic environment versus a nonelectronic environment. I know that, generally, health care providers have file rooms that can be broken into, or maybe they can catch fire, and it is very difficult to reconstruct those kinds of records if they get destroyed. And then, of course, you have to notify people about that loss of information. I would venture to say that [in the non-EHR world] there has probably been a lot of [unauthorized] release of information that went undetected, with minimal consequences and no requirement to tell anyone. Now I think that with the emphasis of HIPAA and the movement toward EHRs, there are penalties for that, and significant legal liability if that happens. And my guess is that the consequences will become more intense as time goes on. I think it’s [going to be] harder to demonstrate [HIPAA] compliance in a

non-EHR situation. Personally, I think there is a qualitative benefit to electronic charting. It lends itself to quality management, to research, to population health and analysis. So beyond the dimension of security risks, there are a lot of clinical benefits. Could you give a brief overview of information-security best practices for the ambulatory physician’s office? Minimum security considerations that any practice transitioning to an EHR should take?

It’s important on the infrastructure side, especially for the smaller providers, to provide an adequate antivirus protection security program. Security breaks down into two big areas: 1) unauthorized access—someone from within or outside of the organization getting into files they should not see; and 2) making sure that there is access to the files when they need to be accessed by the providers or the patient. A whole new area of security is devoted to protecting the network environment from the enormous amount of malware that is becoming available. This will bring down the network, bring down the computers, and, as a result, the provider or patient won’t be able to access needed information because there is a “denial of service” [virus] attack going on. Can you define “malware”?

Any software application that is designed for destructive purposes, such as viruses, worms, Trojan horses. One of the other big pieces of security is training. There is a real awareness in the security industry that security is only as good as people’s understanding of what they are supposed to do [or not do]. A good example is people’s sharing of passwords. The regulations call for annual privacy/security review by the employees of large organizations. We are required to train everybody in privacy and security every year. So the equivalent, if you are running a small- to medium-sized practice with a handful of employees, Continued on the following page . . . May2010 San Francisco Medicine 19 2010 San Francisco Medicine 19 May


Privacy in the Electronic Age Continued from the previous page . . . would be making sure the employees are cognizant of good security practices such as not sharing their passwords, covering up screens, and making sure that information is not accidentally made available to people in waiting areas. For example, many of the viruses that come into networks gain access when people go into commercial websites that are infected by a virus. So it is important for people to be aware of the risks associated with some of the things they might do while they are on the Internet [at work]. Unless you have a training program, you cannot expect people to know that they are not supposed to exchange passwords, for example. An effective part of any security program is raising people’s consciousness with respect to workplace behaviors and how they affect security of information. I also think it’s important for [physicians] to have routine data backup, perhaps with offsite storage. Also, they may consider having their computers, and, if applicable, servers, in a place where not everybody has access. And they should stay current with software upgrades. I would also think a lot of physicians have laptops, so they would want to make sure the laptops are password-protected, any remote connections to their EHR are encrypted, and that they purchase a laptop theft recovery system such as LoJack, which up until now has been kind of expensive but is increasingly standard. And certainly if they are operating a network, they may want to bring in a consultant for help with ensuring the security of the network. What resources or references do you recommend for the nontechnically inclined?

Where I get a lot of information, especially on the privacy side of HIPAA, is from the American Health Information Management Association (AHIMA). HIMSS [Health Information and Management Systems Society] Analytics also has a lot of useful reports. I have found that if

20 San Francisco Medicine May 2010

you go on the Internet and google regulatory compliance in any of these areas, you can find lots of good information from law firm advice websites. And then what I think is happening with the Regional Extension Centers [CalHIPSO] will be helpful for physicians who can apply directly [to CalHIPSO] and get access to consultants for further help. That is something that has never existed before, and they [CalHIPSO] are actually targeting these areas that many providers don’t understand. Any final thoughts on information security that you would like to add?

This is an evolving animal. Number one, the regulations are just beginning to change; and number two, especially on the security side, it’s important to keep in mind the definition of “reasonableness.” I think when you are learning about all of these regulations, it is easy to think, “Oh, my God, how is anybody ever going to fulfill these regulations?” It sounds overwhelming. I could probably spend the entire IT budget on security and still not give our lawyers the 100 percent guarantee that they would like to hear. Nothing is 100-percent secure. But that does not mean that you cannot take reasonable steps. So the regulations emphasize these reasonable steps. As long as you are engaging in well-intentioned, industry-standard compliance, that is the point. The regulations call for reasonable compliance, and that is important for perspective on the area of information security, which can assume dimensions that may or may not be able to be met by anyone. The whole area is so dynamic that it’s impossible to be completely bulletproof all the time.

Hidden Costs, Hidden Savings Continued from page 16 . . . saved money for a solo or small group practice. Period,” he says. “I just don’t think it does. You almost have to be doing it for other reasons.” In addition to conceding that going electronic is the direction medicine is heading, Curran believes another incentive practices have for implementing an EHR system is help with recruiting young doctors. As Curran sees it, small practices are in danger of going extinct largely because the doctors being trained now are harder to recruit and generally less interested in being entrepreneurial and running their own practices. Instead, many prefer the stability of being salaried employees at large practices because of the current insurance model. Additionally, since many physicians today train using EHRs, most aren’t interested in joining practices that have yet to go electronic, he says. These are all reasons Curran wants his current practice to adopt an EHR system sooner rather than later. “It’s kind of like using a Blackberry or anything else,” Curran says. “Unless you do it, you’re not going to get more comfortable with it.” One complicating factor he’s found is that no two minds are exactly alike. “Even in a small group we’re not robots,” he says. “We don’t all have the same practices, so what’s useful for me may not be useful for my partner.” Equally important, Curran notes, are the office staff, who need to be comfortable with the billing and scheduling functions of an EHR system in order to make it a worthwhile investment. He projects that the time it would take to fully transition an office of more than two or three doctors to a point where everything runs smoothly would be at least a year. Curran says the best advice he’s received regarding EHRs is to visit a comparable practice that has implemented a system and talk to the doctors and staff about their experience and the pros and cons of their software. This way doctors can get product testimonials from trusted peers and gain a clearer understanding of some of the ways in which an implementation might affect their practice. www.sfms.org


Health Information Technology

Handheld Technology Update A Review of Gadgets That Will Make Your Work Flow Smoother

Andrew Diamond, MD

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K, I’ll cut right to the chase: You can buy a Tricorder app for the iPad. It will make your iPad behave just like the actual prop held by DeForest Kelley in Star Trek: The Original Series, episode 38. (I recommend the iScanner version because it features DNA analysis, which I’m told is very important.) For those of you interested in devices that are actually useful, the hype surrounding handheld medical technology might be getting a bit noisy. Let’s take a look at what’s really out there, and what might be coming soon. Obviously the most talked-about new toy for doctors this year will be the iPad. However, since I’m writing this a few days before the iPad launches, and since it’ll be a while before any groundbreaking medical software is developed for it, I’ll just say this: The iPad will be fantastic for perusing content such as anatomical images, training videos, journal articles, board review questions, and so on, and one day it will be an utterly amazing tool for interacting with your EHR. But you probably don’t need one today. The year’s second-coolest new toy will likely be the Vscan from GE. No bigger than an obstetrician’s Doppler monitor, the Vscan is an elegantly designed, easyto-use, color-flow-capable, Wi-Fi-enabled ultrasound unit, suitable for examination of the heart, abdomen, urinary bladder, and developing fetus. Want to investigate a murmur, or screen for an abdominal aortic aneurysm, or let your patient watch her baby’s heart beating? Pull this puppy out of your pocket and take a look. Priced at around $7K, it’s a device that could (and, in my opinion, should) alter our notion of the physical exam. But will www.sfms.org

it actually “replace the stethoscope,” as many have predicted? Come on. Which tool would you rather use to evaluate a patient with suspected asthma? Let’s move on to iPhone apps. If you’re lucky, you can already download apps that connect directly to the IT infrastructure of your hospital or clinic. AirStrip Technologies offers a jaw-droppingly cool suite of apps that connect to hospitals’ telemetry, PACS, and laboratory systems. Already in use at several sites around the country, these apps snazzily duplicate the output of ICU monitors, cardiac telemetry monitors, fetal heart tone monitors, image viewers, etc., right on your iPhone screen in real time. Equally impressive is Haiku, a free app from EHR giant Epic, which enables physicians to browse patient charts, review results, renew medications, and more, using a beautifully designed interface. And at Mt. Sinai Hospital at the University of Toronto, an iPhone app from VitalHub is being used to aggregate data from the hospital’s sixty-six different software applications, displaying everything in one clean user interface. While you’re waiting for your hospital or clinic to tap into innovations like these, you can still benefit from stand-alone apps that take advantage of the power of your handheld device. If you dictate chart notes, check out Dictamus, a sophisticated and easy-to-use voice recorder that can send your completed dictations directly to your transcription service. Or consider Dragon Dictation, an app that does your transcribing for you. (Yes, it’s more error-prone than its PC-based brethren, but it’s also free.) Among reference tools, handheld software pioneer

ePocrates has been brilliantly updated for modern devices and now sports new features such as a graphical pill identifier and evidence-based treatment guidelines for hundreds of diseases. If you’re just looking for a comprehensive suite of medical formulae, check out a sharply designed freebie called Calculate by QxMD. And, of course, app stores are full of oldschool, self-contained apps like foreign language medical phrasebooks, anatomy flash cards, ICD-9 code finders, and more. Patients, too, have a host of iPhone apps available to help them manage their health, from pregnancy trackers to life expectancy calculators. One clear standout is Lose It!, a popular and effective weight-loss app that helps patients set goals, establish daily calorie budgets, log food intake and exercise activities, and track overall progress. It’s free and contains no advertising. Even more promising are apps that “close the loop” by allowing patients to monitor their health parameters and transmit the data back to their physicians for review. For example, HeartWise is a well-designed, highly rated, 99-cent iPhone app that lets a patient enter serial blood pressure and heart rate measurements, view and analyze the results graphically, and e-mail the data in spreadsheet form to his or her doctor. BloodWise enables a patient to do the same thing with fingerstick blood glucose data, again for 99 cents. Because such apps are convenient, aesthetically pleasing, and fun to use, they can improve patient activation and compliance. However, let’s be clear: they do not import information directly from monitoring devices, so patients must Continued on page 23 . . . May 2010 San Francisco Medicine 21


Health Information Technology

Technology at Work for You The Brave New World of Information Technology in the Medical Office

Jordan Shlain, MD

M

ost doctors I know are on email, but most do not share those addresses with patients. E-mail is really one of the five main addresses a doctor has: home address, office address, office phone number, cell phone number, and e-mail address. These addresses hold the key to your whereabouts—and in our ever-connected world, your e-mail follows you everywhere, all the time. So it is understandable that a physician would believe that keeping an e-mail address secret would decrease workload. But does it? By turning the “e-mail machine” off, you increase the use of the office telephone machine. And telephones require two people to be actively talking/listening in at the same time. This is why the phrase, “Doctor’s office, could you please hold?” is the chorus and not the refrain when a patient calls. Do you like being put on hold? Exactly. E-mail is asynchronous and can be sent at any time and responded to at any time, thereby giving office staff the ability to prioritize—and become more efficient. The short answer is that changing behavior is difficult for an individual, let alone an entire office. The longer answer is the old saw, “The devil is in the details.” I have been studying electronic medical record systems for more than five years and I’m still not satisfied that any of them understand the work flow of a doctor’s office—or that they understand that trying to create a cookie-cutter, one-size-fits-all system is untenable. Each of us has our own style and believes that our system and processes make the most sense for our practice. Taking the 30,000-foot view, I will

23 San Francisco Medicine May 2010 2010 22 San Francisco Medicine May

make two observations: First, the current iteration of electronic medical records is an attempt by engineers to map current paper flow and digitize it; and second, all EMRs are built on the premise of billing. My first point speaks to that fact that making an electronic filing cabinet based on how paper currently flows is grounded on the premise that paper flow can be converted into a digital program and that paper flow is optimal in the first place. I believe that in the age of technology, we need to conceive of health information differently. Scanning a paper note into a chart and updating a problem list is not the solution to making actionable medical decisions easier. My second point speaks to the problem that the basic foundation of all EMRs is in billing. Did you put in all the data elements to get to a 99214 instead of a 99213? If our purpose in charting becomes to satisfy a billing requirement, we’ve lost something. To be clear, billing is critical. But to create strict criterion makes more work and is why many doctors would rather use paper. I’m not for sloppy paper notes, but when you know your patients and have a command of your style, your paper notes will suffice in determining actionable treatment decisions. My partner, Dr. Swagel, and I have recently been consulting on an EMR called Workflow, and we’ve told them it’s time to change the paradigm. That is, we believe that what a doctor really needs is a visual timeline of what has happened, with the ability to correlate all relevant attributes of care on one page—a mostly visual format. Furthermore, we believe the problem list is what all care should

be oriented around. Each problem should have relevant past labs associate with it, rather than the current rummage through the electronic file cabinet to look up a digitized piece of paper. OK, so you’re saying to yourself, wow, this isn’t helping me decide if and how to use an EMR in my office and in front of my patient. Well, allow me to start being productive rather than critical. I think the current setup with a computer monitor that a patient cannot see is not helpful. I have my office arranged so that my computer is against a wall or on a diagonal, so that my patient can see what I am typing. In fact, I have two monitors: one for my EMR and one with an e-mail opened up and addressed to the patient in front of me. During a typical office visit, there are usually follow-up action items or issues that were discussed, which I want the patient to get by e-mail (I cc my office manager, who also reads the note and attaches it to the chart). This saves the patient from writing down notes on a piece of paper, usually losing it, and not following up. In response to frustration with current communication systems, I recently developed HealthLoop. It does many cool things, but, most important, it’s simple. It is the anti-EMR. It places emphasis on patient communication and office efficiency as opposed to a very expensive and confusing electronic filing cabinet.   A few of the important features include: A secure e-mail messaging system, providing patients with easy access to their doctors, thus increasing satisfaction and compliance. 140-characters maximum space, www.sfms.org www.sfms.org


which encourages brevity. HIPAA compliance. A postvisit e-mail to the patient, requiring just one click to respond about their progress. Then patients are “triaged” according to their responses, with those not progressing well moved to the top for further action. An automated appointment reminder.  Think of HealthLoop like an information prescription, instead of a medication Rx. I am very much looking forward to the Apple iPad. I think that when an EMR is married to a touch-screen tablet that allows voice recognition as well as typing, we will observe the same trend the UPS guy of ten years ago saw as he moved from the paper clipboard to today’s digital signature pad. Health care IT has lagged behind for a myriad of reasons, and we are on the verge of seeing it finally catch up to health care in a meaningful way. We need to start including our patients in our medical “digital age,” because the truth is that they likely already have an iPhone with e-mail! Jordan Shlain, MD, is a practicing internist in San Francisco. He started the first affordable concierge medical practice in the city, www.currenthealth.com. He is also a longtime member of the San Francisco Medical Society.

Handheld Technology Update Continued from page 21 . . . manually enter the data—a notoriously time-consuming and error-prone task. In fact, despite a lot of buzz from several vendors, at this time the only commercially available monitoring device that actually transmits data to the iPhone is the pedometer in the Nike+ running shoe. This will hopefully change as manufacturers solve the challenges of interdevice communication. Eventually we should see user-friendly iPhone apps that gather signals and display data from home blood pressure cuffs, scales, glucometers, and CGM devices, and even ambulatory cardiac monitors. Such apps already exist

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a patient’s home monitoring devices, as well as data from laboratories, imaging services, pharmacies, and consultants, making its way through the cloud to the primary care doctor’s EHR, where it is aggregated, filtered, normalized, interpreted, and delivered back to the patient in real time through a single, unified app on a handheld device. Ahh. . . . Until that day comes, I’ll continue using my iPhone to communicate with patients, using a little-known app called Phone. It works pretty well, except in San Francisco. Andrew Diamond, MD, is a practicing internist and technology design consultant at One Medical Group (www.onemedical. md/sf), a boutique primary care practice in San Francisco. Disclosure: The author has no financial interest in any of the companies or products mentioned above.

for older smartphones (e.g., the Mobile Gateway from Medic4all) but lack the friendly and intuitive interface of the typical iPhone app. On the subject of home monitoring, don’t miss Zio, a very cool, compact, and convenient cardiac rhythm monitor from iRhythm, which is replacing the Holter monitor in many primary care and cardiology practices. Zio sends rhythm data to an analysis center via a standard phone line, and from there via the Web to your EHR. And coming soon, the PiiX cardiac monitor from Corventis will upload data directly to the Web via its own wireless Internet connection. You’ll be able to monitor the vital signs and fluid status of your patients as they putter around their homes. Now that’ll be a reality show. In my opinion, the most exciting innovation in handheld medical technology is just over the horizon: mobile patient portals that allow users to connect to physicians’ EHRs to send and receive messages, view test results, maintain medication lists, and perform other basic transactions. Imagine all the data from

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May 2010 San Francisco Medicine 23


Hospital News CPMC

Michael Rokeach, MD

The Department of Anesthesiology at CPMC “walked the walk” in response to the Haitian earthquake two months ago. Four different members of the department volunteered their time to assist in the effort under trying conditions that involved resourcefulness, perseverance, and commitment. Dr. Barry Rose joined Operation Rainbow, a group that he has worked with many times before in South America. He found himself just across the border in the Dominican Republic in a church converted to a “hospital” with no general anesthesia capability, so the order of the day was regional anesthesia. Dr. Steve Younger relieved him after a week and focused on intensive care work at the same location. Dr. Steve Lockhart headed the first Sutter team, which was located in the town of St. Marc, some 80 miles to the north of Portau-Prince. His team included several CPMC operating room personnel and former CPMC anesthesiologist Dr. Vernon Huang. Dr. Thomas Cromwell joined his Federal Disaster Medical Assistance Team, which he had previously worked with in the Superdome during Hurricane Katrina. They were located in a mobile tent operation room in downtown Port-auPrince. Their workload included everything from major crush injuries to deficiencies to gunshot wounds. Fortunately, all have returned safely. There was an enormous turnout for CPMC Day at Project Homeless Connect this past February. Almost 2,500 clients were served. On the health front, 258 people received medical care (with 64 follow-up appointments); 635 had eye exams and/or received eyeglasses; 58 saw a podiatrist; 31 got wheelchair repairs; 300 got dental screenings; 106 received substance abuse, mental health, or methadone treatment; 91 had acupuncture treatments; 47 saw a chiropractor; and 16 were signed up for mammograms.

24 San Francisco Medicine May 2010 25 San Francisco Medicine May

Kaiser

Robert Mithun, MD

In March 2010, Kaiser Permanente announced that every medical facility within its health system is now equipped with the largest private-sector electronic health record, known as KP HealthConnect®. The system securely connects more than 8.3 million people to their health care teams and to their own personal health information, leveraging a uniquely integrated approach to health care delivery. KP HealthConnect facilitates communication between patients and Kaiser Permanente professionals to help make it easy to access to care and guidance to stay well. For Kaiser Permanente’s physicians, the system is designed to assist them, as well as nurses and staff, in improving quality of care, strengthen communications between the patient and health care team, and enhance the ability to practice personalized health care based on best medical practices. Some of the benefits of the electronic health record include ensuring patient safety with centralized information, coordinated care at every step of the process, and access to accurate, complete patient information twenty-four hours a day. After a successful rollout of KP HealthConnect in the outpatient setting, the system went live in the San Francisco hospital in May 2010. Wireless terminals have replaced handheld paper charts, and quality improvements to the system have been uploaded on a regular basis. Improvements in the EMR program are constantly being made based on suggestions from our medical staff. It was a Herculean effort to implement this EMR in all of the Kaiser Permanente hospitals and medical offices in the United States (431 medical offices and 36 hospitals), and the benefits of using a standardized medical record have already been manifold. We look forward to striving for excellence with the technology available to us, charting a course to deliver the best health care possible in ways that make the most sense.

Saint Francis

Patricia Galamba, MD

Here at Saint Francis, we have taken a giant step into the world of social media. Earlier in March, we launched our blog, painstopshere.saintfrancismemorial.org. This site automatically links you to our Facebook, Twitter, and YouTube sites. The media landscape is dramatically changing and people are using the Internet to seek information on everything, including medical information. They are making decisions based on this information and the endorsements of local providers and programs. With the support of our President/CEO Tom Hennessy, we took the plunge. Saint Francis enjoys a strong following of friends, patients, and staff; it seemed the perfect opportunity for us to stay connected with our constituents and allow a two-way interaction on subjects related to health care. It also provides us with an opportunity to position our physicians as experts in their specialties and provides a new channel for promotion of our events and lectures. The YouTube link hosts a library of more than forty videos, including biographies of physicians, patient testimonials, and interviews on relevant health topics. Check us out on painstopshere.saintfrancismemorial.org. Saint Francis recently underwent backto-back surveys, beginning with an unannounced Medication Error Reduction Plan (MERP) survey by the California Department of Public Health. The surveyor made several recommendations. Plans of correction have been submitted and we await their acceptance. Within a few days of this survey, we hosted the Joint Commission for the recertification of our Stroke Program. Our surveyor was the Joint Commission’s National Director, and she was impressed by the depth of knowledge of our staff and the individualization of care for our stroke patients. The stroke recertification will take us into 2012. www.sfms.org


In Memoriam Veterans

Diana Nicoll, MD, PhD, MPA

A specific region of the hippocampus is significantly smaller in veterans with Posttraumatic Stress Disorder than in those without, according to a study by researchers at the San Francisco V.A. Medical Center. The researchers used MRI to scan the brains of forty veterans—twenty with combat-related PTSD—and found that the region known as the CA3/dentate gyrus was more than 11 percent smaller on average in the veterans with PTSD. The CA1 region was not significantly affected in those with PTSD, according to principal investigator Norbert Schuff, PhD, a senior research scientist. “This is the first time that PTSD has been shown to be associated with changes in certain specific hippocampal regions and not in others,” says Schuff. “The hippocampus is essential for storing and retrieving memories,” explains study author Thomas Neylan, MD. “Because recurring or intrusive memory of traumatic events is a common symptom of PTSD, the hippocampus is of great interest in PTSD research.” The dentate gyrus is a site for the creation of new neurons, while the CA3 region contains receptors for glucocorticoids, which are steroids that are elevated during stress. Neylan says the results raise the possibility that since the dentate gyrus has the ability to create new neurons, “these changes might actually be reversible through treatment.” Schuff cautions that while the results are highly suggestive, they cannot yet be used to identify individuals with PTSD. The findings will need to be replicated independently in a larger population of PTSD subjects in order to eliminate the possibility of spurious results. “This is an incremental step toward establishing a physical biomarker for PTSD,” adds Neylan. “A biomarker is our ultimate goal, since, currently, PTSD is diagnosed based on a subjective neuropsychiatric examination rather than on physical symptoms.” The study appears in the March 2010 issue of Archives of General Psychiatry. www.sfms.org

Richard S. Goodman, MD throughout the Bay Area and beyond. A dedicated physician and teacher, he answered patients’ questions and concerns with clarity and honesty. Working with students, residents, and young doctors was also rewarding to him. On his retirement in 1997, he received an honorary appointment to St. Mary’s medical staff. He was a member of the San Francisco Dermatologic Society, the Pacific Dermatologic Society, and the American Academy of Dermatology. He had numerous interests, such as making wonderful wooden toys, tables, cutting boards, and much sawdust. He loved his elkhound, Happy, and he relished being in the Sierras. He windsurfed on freezing Lake Tahoe before the sport was popular. He enjoyed the Arboretum and Stow Lake in Golden Gate Park. Peaceful, simple things gave him the most pleasure. He loved Beethoven and Mozart and, above all, opera. He had his music with him until the end. Dr. Goodman is survived by his wife of forty-three years, Diana (nee Vest); daughters Karen and Andrea; his brother Allen and sister Shirley Tilsen; and many much-loved nieces, nephews, and cousins. —Nancy Thomson, MD

Dr. Richard Stuart Goodman died on October 10, 2009, age 80. He was born in Milwaukee, Wisconsin, on August 27, 1929, the fourth of six children of Henry and Dora Metz Goodman. He grew up in Milwaukee and graduated from the University of Wisconsin in 1951 and from the University of Wisconsin Medical School in 1954. After a year’s rotating internship at George Washington University Hospital, he began a psychiatry residency at St. Elizabeth’s in Washington, D.C. This was interrupted by service in the United States Air Force in Morocco. When he returned to the U.S., he began a dermatology residency at the University of Chicago Hospitals, which he completed in 1961. After a year’s postdoctoral NIH fellowship, he moved to San Francisco in 1962 and opened his office on Ocean Avenue. The following year, Dr. Goodman was certified by the American Board of Dermatology and became a clinical professor of dermatology at UCSF. In 1964, he joined the San Francisco Medical Society as well as the staff of St. Mary’s Hospital. In 1975, he received additional certification in the subspecialty of dermatopathology and read pathology slides for dermatologists

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Book Review Steve Heilig, MPH

Still Searching for Hope in Haiti “It’s what separates us from roaches” Mountains Beyond Mountains The Quest of Dr. Paul Farmer, a Man Who Would Cure the World By Tracy Kidder Random House; 324 pages; $14.95

T

he cataclysmic earthquake that devastated Haiti in January was really only the latest and most dramatic assault on human health and dignity there. Haiti has long been described as “the poorest nation in the Western Hemisphere,” and now the earth itself has betrayed Haitians. The amount of human suffering there is overwhelming, and our most common response is to turn away in denial and frustration. What can one person do? Paul Farmer does something, and the portrait of him in Mountains Beyond Mountains argues for his inclusion among the highest legions of inspiring human figures. Tracy Kidder, winner of both the Pulitzer Prize and National Book Award for previous books, followed Farmer around the world on his seemingly tireless mission to combat disease among the poorest people in Haiti, South America, and Asia. Kidder contends that Farmer and the issues he confronts are the most important topics he has written about, and he’s done so splendidly here. Farmer grew up in mobile homes as self-described “white trash” and hardly seemed marked for greatness. But by the time he reached 35, he had earned medical and doctoral degrees from Harvard and was a professor there, won a coveted MacArthur “genius” grant, authored two respected books and dozens of important articles, and was renowned in medical and anthropological circles worldwide. Yet all those lofty accomplishments mean less to him than— and were really a means to an end to—his single-minded devotion to healing deathly ill people and preventing diseases such as tuberculosis and AIDS. Along the way, Farmer became acutely aware of—and has tried to attack—”structural violence,” his term for the entrenched inequality and resulting poverty that is the root of much human illness. Inspired by reading Tolstoy and Tolkien as a boy, Farmer won a scholarship to Duke University, where he was “nearly taken in” by the wealth he encountered among preppies there. But after his first trip to the slums of Haiti as a medical student, that seduction was arrested, and Farmer was to wind up what his bookkeeper calls “the hardest-workin’ broke man I know,” as he contributed most of his income, and all the prize money and large sums he raised, to setting up clinics there and health projects elsewhere.

26 San Francisco Medicine May 2010 27 San Francisco Medicine May

Haiti was to become his ministry, if not his primary home. When Kidder first visits Farmer’s clinic “in what seemed to me like the end of the earth, in what was in fact one of the poorest parts of this poorest country in the Western Hemisphere, I felt I’d encountered a miracle.” People carried their sick children for miles on foot over dirt paths to receive expert treatment. “Every patient had to pay the eighty cents, except for the destitute, women and children, and anyone who was seriously ill. Everyone had to pay, that is, except for almost anyone,” Kidder learns. “And no one—Farmer’s rule—could be turned away.” Furthermore, Kidder notes, Farmer’s organization had built schools and clean water systems, vaccinated all the kids around, stopped outbreaks of diseases that devastated other communities, and “reduced the rate of HIV transmission from mothers to babies to 4 percent, about half the current rate in the United States.” And all this was accomplished amid political turmoil and corruption and threats of violence. What drives such a heroic crusader? Kidder returns repeatedly to this personal issue. Farmer himself is succinct in his selfreflections: “One thing that comes back to me . . . if I saved one patient in my whole life, that wouldn’t be too bad. What did you do with your life? I saved Michela, got a guy out of jail. So I’m lucky. . . . To have a chance to save a zillion of them, I dig that.” Still, for all his humanistic urges and actions, Farmer remains something of an enigma and cannot be pigeonholed as some kind of do-gooder. In fact, he castigates “white liberals” who “think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.” What can one person do? This sensitive, compelling portrait just might, beyond its educational value and absorbing reading, spur at least some readers to help with the kind of action Farmer has dedicated his life to, directly or otherwise. Very likely that would be Farmer’s preferred response to his inspiring story. Partners in Health is still on the ground in Haiti, more needed than ever, and any amount of support is put to good use: www. pih.org/home.html.

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Health Policy Perspective Steve Heilig, MPH

Is All Reform Local?

“A

ll politics are local” is a timeworn slogan, with the usual mix of truth and fantasy. The new federal health “reform” legislation is a broad national program, and states and cities are now trying to grasp what it will mean in our own regions. The 2,400-plus pages of the Patient Protection and Affordable Care Act “contains multitudes,” to paraphrase Walt Whitman. It is even more difficult to grasp than Whitman’s poetry. But most notably, up to 32 million Americans—and 80 percent of California’s uninsured—are expected to gain some kind of health insurance coverage, either private or public. Implementation will take years, with many opportunities to alter the outcome, but here are a few developments of local import already underway. Private insurance practices: State authorities have started setting up a Health Insurance Exchange to enroll patients in private options. It is important to note that “if you like your insurance, you can keep it.” Stricter regulation of health insurers is probably the most widely supported aspect of reform. To take just one example, approximately 1,000 Californians per year have had their insurance “rescinded” or canceled by insurers once they got seriously ill. This will be prohibited come September; some major insurers like WellPoint/Anthem Blue Cross, seeing the writing on the wall, have already announced they will no longer rescind coverage. Most of the largest insurers have now received letters from elected officials urging them to do likewise (notably, Anthem has also “rescinded” some hefty rate hikes, which caused such commotion during the reform debate). It will be much harder for insurers to deny coverage due to preexisting conditions, no lifetime caps on coverage amounts will be allowed, and children can stay on parents’ plans until age 26. Expect better coverage for immunizations, preventive care for infants, children, and adolescents, and additional screenings for women. And the reform “[p]rohibits use of practice guidelines for coverage, payment, or policy recommendations.” So much for “cookbook medicine.” Public insurance: Much—up to a third—of the increased coverage of uninsured patients will come via an expansion of Medicaid/Medi-Cal, via eligibility for all qualified Californians. This might not be as bad as it sounds if the planned increase in reimbursement rates—to Medicare rates, roughly—is implemented. But the big question remains as to whether the funds for that will be available. There will be no more MD fees to participate in Medicare, and there will be a 50 percent “bonus” for primary www.sfms.org

care. Where the primary care providers will come from remains to be seen, although there are efforts planned to increase training and availability. In any event, up to 36,000 more San Franciscans could be covered under Medi-Cal, which will at least result in increased funds for public health programs serving many such patients. San Francisco General Hospital, unfortunately, will likely see significant reductions in funds due to cuts in “disproportionate share” funding. In San Francisco, our Healthy San Francisco “universal” coverage program will continue unaltered for the time being. An analysis by the Department of Public Health regarding the impact of federal reform notes, “At this time, the Department is not recommending any changes to the local health programs and initiatives developed in San Francisco.” But significant numbers of patients are expected to move from public programs and public clinics in general as they gain other coverage. A local task force including SFMS representation will monitor and plan for the ongoing “rollout” of health reform locally. Medical quality: The health system overhaul will increase quality data reporting, and it aims at reducing hospital readmissions and nosocomial infections. A planned reporting system for physician performance data, starting in 2013, will be voluntary but “incentivized” via Medicare bonuses until 2015, when penalties would ensue for nonparticipation. The AMA is fighting the latter part. Medical liability: The CMA states that “[f]urther liability relief for California physicians was not forthcoming because we enjoy the strongest law in the country. Our major objective was to protect MICRA and ensure it was not undermined.” Costs: The biggest unknown. Health care’s share of the national economy in 2009 is projected to be 17.3 percent, a record increase to $7,681 per American. Will reform help that? Nobody really knows—there is no reliable null hypothesis for future health spending—but the status quo is and was unsustainable. Which is what this is all about.

Resources

The CMA’s summary of federal reform and the SFDPH’s study of local impact are available from heilig@sfms.org. The AMA has a “How reform affects your practice” page at http://www.amaassn.org/ama/pub/health-system-reform/hsr-impacts-practice. shtml.

May 2010 San Francisco Medicine 27


San Francisco Hep B Free Clinician’s Honor Roll San Francisco Department of Public Health

Aaron Clark, MD Aaron Del Tredici, MD Adam Bellamy, MD Adam Templeton, MD Adela Tam, MD Adil Wakil, MD Adrienne Kane, MD Adrienne Kassis, MD Adrienne Trustman, MD Aileen Dillion, MD Alan Coleman, MD Alan Kramer, MD Alan Leung, MD Alaric Akashi, MD Albert Wong, MD Albert Yu, MD Aldo Gomez, PA Alexander Monto, MD Alexis Williams, MD Ali Alavi, MD Alice Li, MD Alice Tang, MD Alicia Lwin, MD Alisa Oberschelp, MD Alisha Laborico, MD Alvin Wong, MD Amani Zewail, MD Amber Bellamy, MD Amelia Valdez, MD Amin Milki, MD Ana Valdes, MD Anas Hana, MD Andrew Rosenblatt, MD Angel Cho, MD Angela Miller, MD Angela Winn, PA Angela Wong, MD Angelica Andrade-Silverman, MD Angelique Green, MD Anita Carstensen, MD Ann Dallman, MD Ann Kim, MD Ann Omachi, MD Anna O’Malley, MD Anna Sall, NP Anna Silva, MD Annabelle Lee, MD Anne Chang, MD Anne Fukutome, MD Anne Rosenthal, MD Anne Simons, MD Anne Tang, MD

Annelise Goldberg, MD Annette Burns, MD Annette Kwon, MD Anselm Lam, MD Aristotle Mendiola, MD Arlene Keller, MD Arnold Lee, MD Audrey Koh, MD Audrey Tang, MD Ayonija Maheshwari, MD Baljinder Gill, MD Barbara Mak, MD Barbara Trott, MD Barbara Wismer, MD Barry Zevin, MD Bella Berzin, MD Benjamin Fong, MD Benjamin Maeck, MD Bennett Zier, MD Bernard Roazen, MD Berty Liau, MD Betty Ng, NP Bhavna Malik, NP Biljana Horn, MD Bing Foley, NP Bing Xu, MD Bittoo Kanwar, MD Brad Moy, MD Brenda Ngo, NP Bridget Stringer, PA Bryant Lin, MD Carl Bricca, MD Carl Stein, PA Carla Callao, MD Carol Lee, MD Caroline Tsen, MD Carolyn Givens, MD Carolyn Mar, MD Carrie Frenette, MD Carrie Odom, MD Catherine Farrell, NP Catherine Frenette, MD Catherine James, MD Catherine Lyons, MD Charalambos Andreadis, MD Charles Chan, MD Charles Hare, MD Charles Lo, MD Charles Marion, NP Chavez Rai-Cesar, MD Cheresa Ng, MD Chitra Chandran, MD

Cho Angel, MD Christina Clark, NP Christine Crowder, MD Christine Nguyen, MD Christopher Schiessl, MD Christopher Stoehr, MD Christopher Swan, NP Chuk Kwan, MD Clare Cattarin, NP Clare Senchyna, NP Clare Siu, MD Clarissa Ramstead, MD Clifford Wong, MD Collin Leong, MD Collin Quock, MD Collin Smikle, MD Crawford Chung, MD Cynthia Chang, MD Cynthia Farner, MD Cynthia Point, MD Damian Augustyn, MD Dan Kalshan, MD Dana Karlsberg, MD Daniel Chan, MD Daniel Conlin, MD Daniel Greenwood, MD Daniel Null, MD Danny Wu, MD Darrel Robbins, MD Dasi Nie, MD David Bangsberger, MD David Busch, MD David Lown, MD David Malmud, MD David Minor, MD David Ofman, MD David Senechek, MD David Stier, MD David Thom, MD David Tuan, MD David Vernon Paul, MD Dean Rider, MD Deborah Brown, MD Deborah Lindes, MD Denis Bouvier, MD Denise Main, MD Dennis Chen, MD Dennis Shen, MD Derrina Wu, MD Desiree Arretz, MD Diane Rittenhouse, MD Ding Ding Lee, MD Ding Lee, MD

Doan Khong, MD Don Ng, MD Donald Calvo, MD Donald Tarver, MD Donald Zumwalt, MD Dong Hwang, MD Donna Chee, NP Donna Wiggins, MD Dorit Betschart, NP Douglas Corley, MD Dwight Bissell, MD Eddie Cheng, MD Eddie Cheung, MD Edmond Liu, MD Edward Chan, MD Edward Ko, MD Edward Richert, MD Elaine Chien, MD Eleanor Lannen, NP Elena Torello, MD Elias Botvinick, MD Elisabeth Wilson, MD Elizabeth Andrews, MD Elizabeth Galaif, MD Elizabeth Moy, MD Elizabeth Perry, MD Elizabeth See, MD Elizabeth Turner, MD Ellen Chen, MD Ellen Dayton, NP Elsa Tsutaoka, MD Emily Wang, MD Eric Capulla, MD Eric Chin, MD Eric Lantzman, MD Eric Lim, MD Eric Tabas, MD Erica Metz, MD Erica Monasterio, NP Ervin Wong, MD Esther Chan, MD Eva Liu, MD Eva Onyang-Yee, MD Fan Xie, NP Felicia Sterman, MD Fen Chen, MD Flavio Vincenti, MD Foresti Lorente, MD Frances Baxley, MD Frances Wong, MD Francesca Chinn, MD Francis Yao, MD Francis Yu, MD

San Francisco has the highest rate of liver cancer in America. Most liver cancer is caused by hepatitis. Hepatitis and liver cancer are the greatest health gap for Asians and Pacific Islanders. In San Francisco, 1 out of 10 Asian American Pacific Islanders likely has a chronic hepatitis infection that could cause liver cancer. The San Francisco Hep B Free campaign salutes all the doctors and clinicians who are following national guidelines from the Centers for Disease Control and the SF Department of Public Health. They are listed here on our Clinicians Honor Roll.

Media Partners

Frank Farrell, MD Frank Yang, MD Fred Hom, MD Fred Lui, MD Frederica Lofquist, MD Frederick Roll, MD Fung Lam, MD Fung Yee Chan, MD Gary Apter, MD Gary Birnbaum, MD Gary Chan, MD Gary Feldman, MD Gary Friedman, MD Gayatri Khanna, MD Gene Lau, MD Gilherme Campos, MD Ginny Fong, MD Glen Lutchman, MD Grace Fuong, MD Greg Sauers, PA Gregory Fung, MD Gregory Wong, MD Guido Gores, MD Gustin Ho, MD Hal Yee, MD Hali Hammer, MD Hanh Nguyen, MD Hans Yu, DO Hattie Grundland, NP Heidi Wittenberg, MD Heidi Yeung, MD Helen Jackson, MD Helen Lu, MD Hellen Kim, MD Henry Kahn, MD Herbert Goodman, MD Herman Chan, MD Herminigildo Valle, MD Ho Tan, MD Ho Tsuan Tan, MD Holly Holter, MD Hong Wu, MD Hootan Roozrokh, MD Hope Rugo, MD Howard Kleckner, MD Hwaseung Lee, NP Hyo Joong Kim, MD Ingrid Block-Kurbisch, MD Isabel Lee, MD Isabelle Ryan, MD Izumi Cabrera, MD Jack Huynh, MD

Jackie Lam, MD Jacque Duncan, MD Jacqueline Gilbert, NP Jacqueline Kiang, MD Jacquelyn Maher, MD James Chun, MD James Franicevich, NP James Yan, DO Jamila Champsi, MD Jane Bailowitz, MD Jane Fang, MD Jane Wickman, NP Janhavi Guidal, MD Jason Blantz, MD Jason Dimsdale, MD Jason Tokumoto, MD Jean Lee, MD Jeanette Krolikowski, MD Jeanette Lager, MD Jeffrey Golden, MD Jenna Lewis, NP Jennifer Barton, MD Jennifer Chang, MD Jennifer Chin, PA Jennifer Guy, MD Jennifer Lin, MD Jennifer Ross, MD Jennifer Shen, MD Jennifer Siegel, MD Jennifer Tagatz, NP Jerome Franz, MD Jessica Evert, MD Jessica Irwin, PA Jessica Tran, MD Jessica Yu, NP Jiali Li, MD Jian Zhang, MD Jie Ni, MD Jill Lederman, MD Jill Nierman, NP Jimmy Chen, MD Jin Moon, MD Joan Murphy, NP JoAnn Imperial, MD Joanne Kim, MD Joe Goldenson, MD John Fullerton, MD John Ho, MD John Imboden, MD John Nienow, MD John Quatannens, MD John Sun, MD John Tang, MD

John Umekubo, MD John Wu, MD Jon Churnin, MD Jonathan Barash, MD Jonathan Lee, MD Jonathan Lieberman, MD Jonathan Pritikin, MD Jonathan Rapp, MD Jonathan Wong, MD Joo Sock Yang, MD Jordan Horowitz, MD Joseph Leung, MD Joseph Long, MD Joseph Pace, MD Joseph Wu, MD Josephine Mak, MD Joshua Adler, MD Joshua Bamberger, MD Joshua Hanson, MD Joshua Rassen, MD Jovilia Ao, NP Joyce Hansen, MD Juan Larach, MD Judith Sansone, NP Judy Hsu, MD Julia Myint, MD Julie Baller, MD Julie Huh, MD Julie Tse, NP Julieta Gabiola, MD Justin Quock, MD Justin Sewell, MD Ka Kam Chan, MD Kai Ng, NP Kandice Strako, MD Kao-Hong Lin, MD

Clinicians can join the Honor Roll by signing a pledge: (1) to screen patients at risk for HBV infections in accordance with CDC recommendations, and (2) to respond to information requests from the SFDPH regarding patients with chronic hepatitis B. (3) online at http://www.sfhepbfree.org/clinicians/


San Francisco Hep B Free Clinician’s Honor Roll San Francisco Department of Public Health

Kara Chew, MD Karen Bayle, MD Karen Chu, MD Karen Khoo, MD Karen Kwok, NP Karen Tuan, MD Karena Franses, MD Karina Arzumanova, MD Karl Lee, MD Katherine Crosby, MD Katherine Strelkoff, MD Kathryn Kurtzman, MD Kathy Hsiao, MD Katrina Liu, MD Kay Gamo, MD Kay Kugler, PA Kay Yatabe, MD Kelly Wong, MD Kelse McKinley, MD Kenneth Chang, MD Kenneth Gottlieb, MD Kenneth Hammerman, MD Kenneth Mills, MD Kenneth Tai, MD Kevin Man, MD Ko-Myong Lieu, MD Kristen Sherman, MD Kristine Lee, MD Kwokming Cheng, MD Kyi Win, MD Kyo Duck Lee, MD Lam Anselm, MD Lang Huynh, MD Larry Jew, MD Laura Norrell, MD Lauren Poole, NP Lauren Poupard, MD Laurie Green, MD Laurie Nobilette, NP Lawrence Bryson, MD Lawrence Chao, MD Lawrence Joe, MD Lawrence Price, MD Leah Klinger, MD Leah Tessler, MD Lee Chan, MD Lee Liskey, MD Lei Choi, MD Leigh Kimberg, MD Leonid Yankulin, MD Lesley Meister, MD Leslie Kardos, MD

Leslie Squires, MD Levis Owens, MD Lien Luong, MD Lillian Lum-Kaku, NP Linette Martinez, MD Lisa Capaldini, MD Lisa Golden, MD Lisa Lam, MD Lisa Law, MD Lisa Tang, MD Lisa Vuong, MD Lisa Winston, MD Lissette Lopez, MD Lori Kohler, MD Lorna Thornton, MD Lornalyn Carrillo, MD Lorry Larson, MD Lory Wiviott, MD Louis Cubba, MD Louis Kohl, MD Luba Abascal, MD Lyle Shlager, MD Lynne Portnoy, MD Madan Khorshed, MD Madelyn Kahn, MD Madhavi Dandu, MD Mai-Sie Chan, MD Mandana Khalili, MD Marcelle Cedars, MD Marcus Conant, MD Margaret Chen, MD Margaret Fang, MD Margaret Stafford, MD Maria Tong, MD Maria Wamsley, MD Maricar Pacquing, MD Marie Lewandowski, MD Marie Palazuelos, MD Marion Peters, MD Mari-Paule Thiet, MD Marjorie Smith, MD Mark Herman, MD Mark Higgins, MD Mark Savant, MD Mark Schultz, NP Mark Shimazaki, MD Mark Sorensen, MD Mark Tsuchiyose, MD Marlena Tang, MD Martin Garcia, MD Martin Kramer, PA Martin Leung, MD Martin Liberman, MD

Martin Mass, MD Mary Hicks, NP Mary Kemeny, MD Mary Mays, MD Mary Newberry, MD Marya Zlatnik, MD Matthew Mei, MD Maurizio Bonacini, MD Maxwell Janosky, MD May Yau, MD Meenakshi Jain, MD Mei Allison, MD Mei-Lai Lucas, MD Mei-Ling Fong, MD Melody Lee, MD Merik Gross, MD Michael Blumlein, MD Michael Caplan, MD Michael Chase, MD Michael Potter, MD Michael Sdao, MD Michael Vaughan, MD Michael Verhille, MD Micheal Rabow, MD Michele Borgeson, MD Michelle Guy, MD Michelle Mourad, MD Michelle Orengo-Mcfarlane, MD Michelle Roland, MD Michelle Tam, MD Michelle Tang, MD Michelle Tisi, MD Mideo Luk, NP Milton Estes, MD Mina Abazari, MD Ming Chih Kao, MD Ming Quan, MD Ming Tsang, MD Minnie Wood, MD Miranda Surjadi, NP Miriam Sheinnein, MD Monica Singer, MD Morton Cowan, MD Muhammad Hassanein, MD Nadgeda Moore, MD Nadine Burke, MD Najwa El Nachef, MD Nally Tsang, MD Nancy Zinn, NP Nang Du, MD Nardine Saad, MD

Natalie Bzowej, MD Nathan Bass, MD Nicholas Jew, MD Nilda Alverio, MD Norah Terrault, MD Olin Lau, NP Pamela Chan, MD Pansy Fong, MD Pao Ching Wang, MD Patricia Galamba, MD Patricia Gibbs, MD Patrick Pan, MD Patrick Wong, MD Paul Chu, MD Paul Garcia, MD Paul Quick, MD Paula Cahill, NP Paula Lum, MD Pearl Yee, MD Peg Strub, MD Peggy Newcomer, DO Peir Gen Chiu, NP Peter Berman, MD Peter Ewald, MD Peter Hui, MD Peter Lee, MD Peter Lin, MD Peter Ng, MD Peter Remedios, MD Peter Yeo, MD Philip Chow, MD Phillip Rosenthal, MD Phoebe Pang, MD Pooja Mittal, MD Prasanna Jagannathan, MD Quock Fong, MD R. Todd Frederick, MD Rachel Shu, MD Randall Low, MD Raphael Merriman, MD Raymond Li, MD Raymond Liu, MD Raymond Louie, MD Rebecca Amirault, MD Rebecca Jackson, MD Rebecca Siegel, NP Rebecca Yee, MD Reena Gupta, MD Renee Pacheco, MD Richard Cazen, MD Richard Dolbec, MD Richard Gibbs, MD

San Francisco has the highest rate of liver cancer in America. Most liver cancer is caused by hepatitis. Hepatitis and liver cancer are the greatest health gap for Asians and Pacific Islanders. In San Francisco, 1 out of 10 Asian American Pacific Islanders likely has a chronic hepatitis infection that could cause liver cancer. The San Francisco Hep B Free campaign salutes all the doctors and clinicians who are following national guidelines from the Centers for Disease Control and the SF Department of Public Health. They are listed here on our Clinicians Honor Roll.

Media Partners

Richard Huynh, MD Richard Levy, MD Richard Loftus, MD Richard McKinney, MD Richard Sundberg, MD Richard Tang, MD Richard Ward, MD Richardo Alvarez, MD Ritika Aulakh, DO Robert Bartz, MD Robert Elsen, MD Robert Franklin, MD Robert Gish, MD Robert Marshall, MD Robin Anderson, MD Robin Serrahn, MD Robin Wallace, MD Roger Iliff, MD Ronald Tempesta, MD Rong Shen, MD Rosa Valadao, MD Rosalia Mendoza, MD Rosamani D’Souza, MD Rosanna Chow, MD Ryan Gorton, MD Sal Fazio, MD Sandy Wu, MD Sansan Tin, MD Sara Woolf, MD Sarah Kureshi, MD Sarah Lowenthal, MD Sarah Malin-Roodman, NP Sarah White, MD Scott Biggins, MD Scott Huang, MD Scott Tsunehara, MD Scott Weber, MD Seck Lam Chan, MD Seth Feigenbaum, MD Shandra Yoshimi, MD Sharon Meyer, MD Sharon Wong, MD Shawn Hassler, MD Sheena Kong, MD Shelley Fung-Yeung, MD Shih Jen Chang, MD Shilpa Chari, MD Shilpa Keny, MD Shirley Leong, MD Shotsy Faust, NP Shu-May Lee, MD Shu-Wing Chan, MD

Si Hao Lam, MD Siew Loong Tso, MD Silvia Yuen, MD Simon Lee, MD Sofia Pan, MD Son Lam Nguyen, MD Sonal Patel, MD Sonia Bledsoe, MD Sonia Soo Hoo, MD Soraya Azari, MD Spencer Lowe, MD Stefan Chin, MD Stephanie Chun, MD Stephanie Lowe, MD Stephanie Scott, MD Stephen Lee, MD Stephen Pardys, MD Stephen Tomlavovich, MD Steve Leiner, NP Steven Chan, MD Steven Fugaro, MD Steven Katznelson, MD Steven Thompson, MD Stewart Cooper, MD Stewart Wong, MD Sumana Kesh, MD Su-Mui Kuo, MD Susan Bertolli, MD Susan Coffey, MD Susan Huang, MD Susan Shea, NP Susan Young, MD Suzannah Stout, MD Tami Daugherty, MD Tammy Lee, NP Ted Li, MD Terence Friedlander, MD Teresita Degamo, MD Thang Nguyen, MD Theresa Moore, MD Thomas Haddad, MD Thomas McClure, MD Timothy Davern, MD Tina Lee, MD Toby Dyner, MD Todd Pope, MD Tony Wong, MD Towie Fong, MD Tracey Robinson, MD Tuan Duong, MD Tuan-Anh Hoang, MD Tuong Do, MD Ummehani Khuddus, MD

Urmimala Sarkar, MD Van Selby, MD Vernon Fong, MD Veronica Louie, NP Veronica Lozada, MD Victor Fujimoto, MD Victor Huie, MD Victor Lyapis, MD Viktor Schranz, MD Virginia Cafaro, MD Virginia Dolezal, NP W. L. Chan, MD Wai-Man Ma, MD Walford Fessel, MD Warren Choy, MD Weiwen Zheng, MD Wellman Tsang, MD Wendy Ho, PA William Chung, MD William Hagbom, MD William Naber, MD William Owen, MD William Parmer, MD Winnie Yuba, MD Yael Schenker, MD Yan Xu, MD Yannick Leguyader, MD Yao Heng, MD Yetta Guan, MD Yi Jiang Shi, MD Yinn Tzeng, MD Yong Liu, MD Yuan Da Fan, MD Yulia Koltzova Rang, MD Yulia Rang, MD Yuwen Xu, MD Zhi Huang, MD

Clinicians can join the Honor Roll by signing a pledge: (1) to screen patients at risk for HBV infections in accordance with CDC recommendations, and (2) to respond to information requests from the SFDPH regarding patients with chronic hepatitis B. (3) online at http://www.sfhepbfree.org/clinicians/


In My Opinion Steve Askin, MD

Lowering Health Care Costs

T

he health care reform bill has been passed by Congress and signed by the President. Though certain benefits were included, the main problem—the rising cost of health care—was not addressed. I would like to present two actions that would have cost-lowering effects. The first is the support and promotion of health savings accounts (HSAs). HSAs, first called “medical savings accounts,” have been in existence for about ten years. As of 2008, there were more than 6 million people signed up for such plans. The HSA is a savings account accompanied by a highdeductible health insurance policy. The insurance, designed to cover a major illness or accident, should be much cheaper than other policies. Ordinary health care is to be paid for out of the savings account itself. Contributions to that account are of about the amount of the deductible—now about $5,000—so when the deductible is spent, the insurance should kick in. Currently, legislation specifies the upper limit of the yearly contribution, which can be made by the account holder, the employer, both, or anyone else. The contribution is tax deferred and can be used for medical care, tax free. If the money is used for nonmedical purposes, tax plus a 10-percent penalty must be paid. When the deductible is used up, the HSA can be used for uncovered expenses, such as copayments. Unused funds can be rolled over from year to year. At age 65, the client is no longer eligible for the HSA plan, but he can use the remaining funds for anything after paying taxes on it. The HSA emphasizes individual ownership and control. The health savings account is owned by the client and is portable, moving with him or her from job to job. As 67 percent of patients spend less than $5,000 yearly for health care, the account will cover most people adequately. Dealing with expenses simply involves writing a check from the account to the provider—no need to verify eligibility with an insurance clerk, for example. This lack of overhead translates into lower costs for the patient. The patient would also have the freedom to choose his physicians, including consultants, laboratories, and radiology facilities. Theoretically he could even negotiate lower prices. For employers with at least half of their employees enrolled in HSAs, health care costs rose 3.6 percent in the past two years. Employers who did not offer this plan experienced a 7 percent rise in health care costs (Stark). Another advantage is the ability to decrease the number of uninsured. Up to 40 percent of

30 San Francisco Medicine May 2010

signups for HSAs are previously uninsured patients. Negative predictions have been proven untrue by studies. Some said the plan would be used only by the young, healthy, and rich; others claimed it would not encourage preventive care. If rates for high-deductible insurance plans are rising, this could be dealt with by the market, by legislation, by pressure on insurance companies, and by increasing the deductible. A major fear is that legislators, in their zeal to improve health care, may impose unreasonable requirements that interfere with the highdeductible insurance. These requirements must be watched for and strongly opposed. The second area in which to lower health care costs is in the realm of tort reform. In California, we are lucky to have tort reform already. The malpractice insurance crisis of the 1970s brought an out-of-control system to the forefront: Insurance was unavailable in many cases, costs skyrocketed, physicians moved away to cheaper areas. The end result was legislation in Sacramento. A limit was placed on lawyers’ fees in the form of a fee schedule; awards for pain and suffering were limited to $250,000. The crisis passed and reasonable premiums resulted, despite protests by the trial lawyers. However, this not the case nationwide. Some specialists in certain areas pay more than $100,000 yearly for professional liability insurance. Patients are deprived of needed care. Physicians practice defensive medicine to protect themselves against lawsuits. Physicians add thousands of dollars to their expenses—a cost that is passed on to patients and their insurance carriers when possible. This clearly increases the cost of health care, which could be lowered by nationwide tort reform. It will bring on a battle with trial lawyers, who are well represented in Congress, but would be a worthwhile and noble battle. Steve Askin, MD, practiced general surgery for thirty-six years. Now retired, he lives in Sebastopol where he farms apples and vegetables and sings in the Marin Men’s Chorus. He is also a member of the editorial board for San Francisco Medicine.

References

Health savings account. Wikipedia. Health savings accounts. Askin, Stephen. San Francisco Medicine. Stark, Roger. Health Care Reform That Works: An Update on Health Savings Accounts. The Washington Policy Center. www.sfms.org


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May 2010