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CAN TECH REVOLUTIONIZE MEDICINE? NEW TECHNOLOGIES: PROGRESS AND PERILS The Digitization of Health Care: Disruptive and/or Wonderful? Interviews with Medical Leaders Drs. Jack Resneck and Robert Wachter The Promises of New Wearable Technology Telemedicine: A Healthy "Social Media" Applying a Design Thinking Framework to Medical Education

Plus: 2019 Annual Gala Wrap-up! Volume 92, Number 1 | January / February 2019


SAN FRANCISCO MARIN MEDICINE January/February 2019 Volume 92, Number 1





Membership Matters


President’s Message: Innovation for All of Us Kimberly L. Newell Green, MD


Medicine & Medical Technologies: Progress and Perils Kimberly L. Newell Green, MD and Steve Heilig, MPH, with Jack Resneck, MD Unlocking Health Care Steve Bini, MD and Saul Marquez

10 EHR Angst: The Second Wave Solutions Michael Scahill, MD

12 The Digitization of Health Care: Disruptive or Wonderful? Robert M. Wachter, MD

32 CMA 2018 Year in Review

36 Community News: Kaiser Permanente Maria Ansari, MD 36 Upcoming Events

16 The Past and Present Future in Medical Technology Graham Walker, MD


20 Telemedicine: A Healthy “Social Media” James Wantuck, MD

28 2019 Annual Gala Highlights

18 To Solve a Complex Healthcare Challenge, Focus on Your Mission Larry Ozeran, MD

22 Wearing Your Health on Your Sleeve: The Promises of New Wearable Technology Kimberly L. Newell Green, MD

4 Introducing Kimberly L. Newell Green, MD 26 In Memoriam: Jeffrey Stevenson, MD, Richard Cohen, MD, and David Willett, Esq.

31 Media Statement: Affordable Care Act 36 Advertiser Index

24 Applying a Design Thinking Framework to Medical Education Jyothi Marbin MD



Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web:

MEMBERSHIP MATTERS CMA Announces New Statewide Effort to Promote Physician Wellness To help physicians succeed in their life's work of caring for patients, the California Medical Association (CMA) has made physician wellness and the prevention of burnout a core priority. CMA is working with nationally recognized leaders on physician wellness who bring unparalleled academic expertise and handson experience to build an organizational initiative to improve physician fulfillment and well-being. The new initiative is a statewide collaborative effort with physician wellness experts from the Stanford Medicine WellMD Center: Tait Shanafelt, M.D., associate dean, chief wellness officer and professor of hematology; and Mickey Trockel, M.D., project co-leader and clinical associate professor of psychiatry and behavioral sciences. Under the leadership of CEO Kathleen Creason, CMA’s Physician Wellness Services will be the most comprehensive effort in the country to increase physician wellness as a vehicle to improve the quality of care they provide patients. Read more at

CMA Recoups $29 Million on Behalf of Physician Members California physicians have a powerful ally when it comes to dealing with problematic payors—the CMA Center for Economic Services (CES). Staffed by practice management experts, the CES team has recovered $29 million from payors on behalf of its physician members over the past 10 years. In 2018, CES had a record year, recovering nearly $11 million from payors on behalf of physician members, up from $3 million in 2017. This is money that would have likely gone unrecouped if not for CMA’s direct intervention. CMA members can call on CMA’s practice management experts for FREE one-on-one help with contracting, billing and payment problems. Contact CMA’s reimbursement helpline today at (888) 401-5911 or economicservices@cmadocs. org. Learn more about how CMA’s practice management experts can help you at

Pharmacy Board Says “Enforcement Not a Priority” for New Security Prescription Law

On January 1, 2019, a new California law took effect that requires all security prescription forms to have a uniquely serialized number, and also requires physicians who prescribe controlled substances to use updated controlled substance prescription forms. The legislation did not include any transition or grandfathering period to allow for continued use of old controlled substance security prescription forms on or after January 1. The California Board of Pharmacy recently said it would “not make enforcement a priority” if pharmacists choose to fill prescriptions written on security prescription forms that were compliant prior to January 1, but are not compliant with the new serialization requirement. Similarly, the Medical Board of California has also recently issued a memorandum emphasizing the pharmacy board's decision not to aggressively enforce the new requirement. Physicians should make sure their security prescription vendors are ready to comply with the new requirements. CMA's security prescription partner, RxSecurity, is now taking orders for the new uniquely serialized prescription forms. Read more at



SFMMS leaders met recently with SF Supervisor Catherine Stefani to discuss gun control and public health. From left, SFMMS President Kimberly Newell Green, MD, John Maa, MD, Catherine Stefani, Judy Melineck, MD, SFMMS CEO Mary Lou Licwinko.

Reminder: Be Prepared for Covered California Changes in 2019 In 2018, Covered California, California's health benefit exchange, enrolled approximately 1.48 million individuals in qualified health plans. With a limited number of changes set to occur for 2019, it remains critical that physician practices understand their participation status, which products are being offered and what changes to expect. To see some of the most significant changes for Covered California in 2019, go to

CMS Completes Issuance of New Medicare ID Cards

The Centers for Medicare and Medicaid Services (CMS) has completed the process of mailing new Medicare cards to beneficiaries across all states and territories. The new Medicare ID cards, required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), contain a unique, randomly assigned Medicare Beneficiary Identification (MBI) number, which replaces the previous Social Security-based number. CMS is allowing a 21-month transition period (which began in April 2018), during which health care providers will be able to use either the patient’s current Medicare number or the patient’s new Medicare number for all Medicare transactions. The transition period will end December 31, 2019. While providers can continue submitting claims with the old ID numbers during the transition period, physicians are encouraged to use the new MBIs as soon as possible for all Medicare transactions. For more information, please visit WWW.SFMMS.ORG

THE SFMMS POLITICAL ACTION COMMITTEE THANKS YOU! The SFMMS PAC thanks the following recent physician donors to our work building relationships and advocating for healthy policies with local and other elected officials.

James Adams Tomas Aragon Vamsi Aribindi Richard Caplin Richard Caplin Shannon Constant Anne Cummings Roger Eng Lizellen Follette George Fouras

Steve Fugaro Gordon Fung Erica Goode William Goodson Robert Harvey Kevin Hiler Michael Kwok Benjamin Lau Man-Kit Leung Ronel Lewis

John Maa J Fraser Muirhead Gordon Preston Monique Schaulis Michael Schrader James Storm Winnie Tong Charles Wibbelsman Joseph Woo

January/February 2019 Volume 91, Number 9 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Guest Editor Kimberly L. Newell Green, MD Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Obituarist Erica Goode, MD, MPH Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Erica Goode, MD, MPH Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Kimberly L. Newell Green, MD President-Elect Brian Grady, MD Secretary Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, MPH, PhD, FACP Immediate Past President John Maa, MD Editor Gordon L. Fung, MD, PhD, FACC, FACP SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke


Membership Coordinator Ruben Pambid


Executive Assistant/Office Manager Ian Knox

JOIN OR RENEW TODAY When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health. Working together with you, SFMMS unites physicians to champion health care initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes. We cannot do this alone. Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Renewing is easy: 1. Mail/fax your completed renewal form when you receive it in the mail; or

2019 SFMMS BOARD OF DIRECTORS Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen N. Kumar, MD Michael K. Kwok, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD William T. Prey, MD Justin P. Quock, M Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD

2. Renew online at with a credit card.





Introducing Kimberly L. Newell Green, MD The 2019 President of the San Francisco Marin Medical Society Why did you choose a career in medicine? I loved science and math growing up and thought I would be a scientist, but in college I fell in love with the humanities. Medicine seemed a perfect combination of science and the humanities.

How did you choose your medical specialty?

When I was contemplating a career in medicine I spent a summer working with a renowned pediatric surgeon at Children’s National Medical Center in Washington DC. I loved being in the setting of caring for children: I knew that I would work hard as a physician, and intuited that somehow the burden of that work would be lightened because I would be seeing a sick kid rolling herself down a hospital hallway giggling, or watching the transformation from sick to completely well that happens after a pediatric illness. Kids are wonderful teachers about the power of the body, mind and spirit.

Why are you a member of SFMMS?

Medicine is in great transition and I believe that it’s vital for physicians and healers to be front and center in all of the arenas in which the details of that change are being decided. I am incredibly impressed with the values, the skills, and the community of SFMMS: I am honored to work with a passionate and generous group of physicians and staff that understands how to advocate for important public health and patient-related concerns.

Can you tell us about any goal(s) you hope to accomplish during your term as SFMMS President?

I will bring my own experience, passions and skills to this role. As such, I hope to focus our community on the importance of children to all of us, no matter our speciality; to inspire our members to take an active role in the changes happening within medicine - especially technological changes; and to help us all retain or regain joy in the practice of medicine by highlighting evidence-based wellness practices and also by advocating for operational and policy focus on physician job satisfaction.

What are some of the biggest opportunities or challenges you see in health care within the next year, and within the next three to five years?

Within the next year, I fear that the continued assaults on the Affordable Care Act and uncertainty about the impact of judicial and legislative actions on the stability of our national healthcare system will leave providers and patients feeling anxious and uncertain, and will likely negatively impact care delivery, the experience of care and caring, and ultimately health outcomes. I suspect this issue will continue to unfold over the next three to five years and be a source of stress in our work. In terms of transforming healthcare, I do believe that the next 3-10 years will see some incredibly exciting opportunities, including the ability to use data to deliver significantly better care, the development of systems that will extend our care from inter4


mittent face-to-face visits to continuous remote care augmented by technology and a team care approach, and also a robust focus on physician and caregiver wellness that I hope will reverse the worrisome trend in that arena. These opportunities will bring great change in the way we practice day to day, and physicians will need to be flexible in order to evolve with the system.

How do you balance your work and personal life, and still manage time to participate in SFMMS activities?

My daughter was looking over my shoulder as I answered these questions and she remarked that “Mama, that question looks hard!” And I would agree. In my family life and my career it has been vital for me to have a very clear understanding of my values and make all of my decisions based on those values: at this phase of my career, having flexibility to be present for both my family and the work that I choose to do is vital. That means saying no to many opportunities and being very clear with my boundaries. But I also know that being a part of the transformation of healthcare, keeping the health of patients and physicians clearly in the center of every decision I make and all of the work I do, is vital to me fulfilling my own personal mission. Having clear values and a mission statement based on those values helps all of my decisions become clear.

Any advice for new physicians transitioning into practice from residency?

Stay humble. Realize that you cannot know everything and you will make mistakes. Listen to your intuition. And put on your own oxygen mask first.

What about you would surprise our members? What’s something we might not know about you?

Once I decided to become a physician, I figured I’d be doing that for the rest of my life. So as an undergraduate I took the bare minimum of pre-med requirements and then spent the rest of my time on wide ranging intellectual adventures in the humanities. I majored in comparative religion and spent a year after college in India on a Fulbright Grant studying a sect of Hinduism, was a ski bum in Vail Colorado for a year, and then produced a documentary-style educational film about cross-cultural health care funded by the Harvard School for Public Health. Oh, and my daughter wanted me to mention that I’m lefthanded and have the ability to make a cloverleaf tongue.

If you weren’t a physician, what profession would you most like to try?

Oh wow, that’s perhaps the hardest question yet. I can imagine so many amazing things to learn and do! I do love the visual arts and would love to be a museum curator. I also love story-telling and think that journalism would be incredibly fulfilling. WWW.SFMMS.ORG

PRESIDENT’S MESSAGE Kimberly L. Newell Green, MD

INNOVATION FOR ALL OF US I believe that it is through story that we retain our human connection in the face of the great confusion and division our nation faces. It is with an ear to the ground and and eye to the future that I will sit at the head of this organization, and listen, and learn, and advocate. It is with great honor that I write this first of my president’s messages in the San Francisco Marin Medical Society journal. I come with a great deal of humility, and grati-

tude for the many members, leaders and staff of this organization who have done so much ahead of me. Being only the 7th woman to hold this office, and one of only a handful of pediatricians, I plan to bring to bear my own skills, interest, experience—and perhaps even some wisdom—to this role. As a general pediatrician at Kaiser Permanente for more than a decade, I worked to care for the young and vulnerable who are our future. Our future doctors, our future governing officials, our future teachers, our future engineers: these children will serve us all in ways that we can only begin to imagine now, and I firmly believe that it is the responsibility of all of us to make sure that this generation of children is raised in a world in which they can thrive. I also had the privilege of being the Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco during my years there. In this role I had time and space to think deeply about an issue that we all hear about nowadays: The struggle of many physicians to find and retain their joy in practicing medicine. This issue is becoming both more pressing, and also hopefully more solvable, as the great minds within medicine work together to support and promote the health and wellness of the healers in our society. Another issue in which I was deeply involved as the Chief Healthcare Innovation Officer of Kaiser San Francisco was thinking about how healthcare and the practice of medicine are changing. A rapid transformation of American medicine is happening at a time of an explosion of promising innovations in science and in technology, and also at a time when the staggering cost of healthcare is threatening to overwhelm not only our individual practices but also health systems and hospitals and even the economic fabric of our entire nation. As you will see in this issue of our journal that I have been privileged to help edit, we have a long way to go in navigating the path towards ensuring that the digitization of healthcare is not only disruptive, but also wonderful. Saying that I am a doctor who is working to use technology to transform healthcare is not a neutral statement. This passion is met with a variety of responses, including great excitement and also great skepticism, negativity, and cynicism. It is true that for many of us that early advances of technology into our profession has been awkward and painful. The hope that we WWW.SFMMS.ORG

could use technological tools to help make the quality of the care we deliver better, safer, and less costly have largely been undermined by imperfect early versions of systems that have often made our days longer and our connections to our patients seem tenuous. I am, however, extremely hopeful. Our medicine has to change, because it is too expensive and too difficult to care for all of the millions of Americans from infants to the elderly who need healthcare, who need healing. These consumers of modern healthcare have high expectations, as they should. I view the digitization of healthcare through a lens of optimism and also with a deep belief that physicians must be intimately involved in making the technological advances in healthcare work for us, so we are armed to make our patients healthy and so that we can again thrive in this important work we do. With this belief, I have asked an amazing group of physicians to share their experiences in this vital work. I recently sat down with the September 2018 issue of this journal to help judge our medical student/resident writing contest. If you haven’t read these short essays, I would highly recommend that you grab a cup of tea and settle in for a wonderful, heartening reminder of why we do what we do. These students share their stories with such power. They’re literary. They’re intimate. They’re poetic. They’re tender. They’re vulnerable. They’re precise. They’re wise beyond their years. I believe that it is through story that we retain our human connection in the face of the great confusion and division our nation faces. It is with an ear to the ground and and eye to the future that I will sit at the head of this organization, and listen, and learn, and advocate. I will be thinking about how to transform our practices, our care systems and our laws so that our children and families, our physicians, and our healthcare system can grow and thrive in a very new world. I look forward to hearing from all of you, our members, with your hopes and dreams, your ideas and plans, because we all need to be a part of the changes that are happening around us. Kimberly Newell Green, MD is a pediatrician in San Francisco and Assistant Clinical Professor at University of California School of Medicine. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco where she practiced as a general pediatrician for over a decade and was a member of the senior leadership team.




Can Tech Revolutionize Medicine?


Jack Resneck, MD, Interviewed by Kimberly L. Newell Green MD and Steve Heilig, MPH Telemedicine would seem to be most appropriate for some specialties, including your own, dermatology. What do you think its biggest impact might be on medicine in general? Telemedicine has enormous potential to increase access to care, and my specialty of dermatology has certainly been among many other early adopters. Like any other new care delivery model, telemedicine can be deployed well or poorly, and I’ve certainly seen spectacular as well as scary examples. When it allows patients to follow-up more easily with a physician or practice who knows them and their history, it can be incredibly convenient and can provide highly coordinated care. It can also be very useful when used from one clinician to another – for example, when one physician can send a consultation with photographs or other data to get a quick opinion from another physician. But some of the direct-to-consumer telemedicine we have seen growing in recent years is providing fragmented, low-quality care in return for convenience. I published a study in which medical students posed as patients and uploaded photos from the web and structured classic case histories to see what diagnoses and prescriptions they got from some of these online sites, and the results were disturbing. Most of the corporate sites aren’t giving patients a choice of the clinician who will care for them or disclosing the credentials of those clinicians. Some of these sites were even using doctors who aren’t licensed in the US. We also found that these sites were regularly missing important diagnoses, and prescribing inappropriate medications without discussing risks and sideeffects, putting patients at risk. Perhaps the biggest problem with many of these sites is the lack of coordinating care for patients – most of them didn’t offer to send records to a patient’s existing local doctors. And when patients end up needing in-person care if their condition worsens, or they have a medication side-effect, those distant clinicians often don’t have local contacts, and are unable to facilitate needed appointments. Physicians have embraced innovation in healthcare delivery for decades, and recognize that digital health, including highquality telemedicine, holds great potential to improve access to care and care coordination. The profession of medicine has also recognized that the fundamental professional and ethical responsibilities to deliver high-quality, coordinated care are unchanged by these evolving technologies. I strongly believe that when telemedicine is driven by physicians, bringing our focus on quality and our values to the table, it has enormous potential to improve access and convenience, and I’ve seen examples of physicians in a variety of specialties doing an outstanding job. 6


The AMA and state medical societies are pursuing state legislation that improves access by strengthening reimbursement for high quality medical care provided using telemedicine. When physicians provide medical care to their patients through coordinated telehealth that meets the applicable standard of care, public and private health plans should cover those services. We’ve made some great progress at CPT developing new codes for telehealth, and are beginning to see Medicare expand coverage—I had the privilege to testify before Congress about this issue, and we have continued to press for expanded coverage. But we also want to ensure that minimum safeguards are met in order to qualify for coverage—patients seeking telehealth services should be able to choose their clinician, know the credentials of the person providing care, and receive care meeting the same standards as that delivered in person. Perhaps most importantly, telehealth services must coordinate care with patients’ existing healthcare teams and should operate only in geographic areas where they have local backup for when patients end up needing in-person care if their condition worsens or they have a medication side-effect.

One of the technologies that has impacted physicians the most thus far, EHRs, is widely seen as a mixed blessing, contributing to burnout. How do you see that evolving and hopefully improving over time?

When I’m traveling the country, speaking with other frontline physicians in my role as AMA Chair, frustrations with clunky EHR products are the #1 complaint I hear (closely followed by everexpanding prior authorization burdens). I wouldn’t want to go back to paper—but I share the frustration that my EHR hasn’t delivered yet on the promises of usability and interoperability. An AMA study found that for every hour of face-to-face time with patients, physicians are spending two additional hours on EHR and clerical tasks—and that doesn’t even include the time we spend in our pajamas each evening finishing up our notes and cleaning out in-baskets. We need technology that is a joy to use and consistently helps with patient care rather than putting burdens between physicians and our patients and driving burnout. So at AMA, we have created EHR usability standards, are evaluating common EHRs on user-centered design, and are pushing regulators to hold vendors accountable for data blocking and a lack of interoperability. We’ve also convinced CMS to allow more members of the healthcare team to document in the EHR so the burden does not rest solely on physicians. We are also investing heavily in innovation—so that future health technology doesn’t get created by investors and entrepreneurs without physicians at the table. We have WWW.SFMMS.ORG

launched a Silicon Valley enterprise called Health 2047 focused on developing bold, physician-led solutions for data liquidity, re-engineering chronic care delivery, and helping physicians get time back during their busy days. And we’ve launched our Integrated Health Model Initiative to organize the data overload we all face—achieving interoperability will only frustrate us if what we end up with is thousands of pages of medical records from which we can’t pull the most critical data. I strongly believe that physicians must be the ones boldly driving healthcare innovation – so that new technologies actually work and do what they say they will, fit seamlessly into our physician workflows, and provide data security. I’m an optimist, and despite my current frustrations, I think that putting physicians in lead roles in digital health development alongside the right partners will eventually get us to a place where we have technologies that are a delight to use and support us as we spend time caring for patients.

What is on your personal wishlist for technology in healthcare: what problems would you most like solved?

While I’m sometimes excited about the possibility that augmented intelligence will be able to provide predictive analytics that truly gives me information that I need at the moment I need it, most days I just wish for some far more basic technology problems to be solved. For example, while we work to address skyrocketing drug prices, I think most physicians are suffering under a substantial burden of increasing prior


authorization requests from insurers—and it puzzles me that our computers can’t seem to accurately and consistently tell us at the point of care which drugs and tests are covered by a patient’s insurer, what copays will be for each option, and whether prior auth will be needed. And in an era when we physicians are being evaluated on our cost of prescribing and total cost of care, it would be helpful to transparently know the actual cost of medications (after the secretive rebates, discounts, and kickbacks that are part of the pharmaceutical pricing chain) right when we are prescribing and discussing options with our patients. This ought to be seamless, but it isn’t, and it’s frustrating to us and to our patients. At AMA, we are pushing health plans (and state legislators) not only to make prior auth less burdensome, but also to provide us with these critical data at the point of care, and allow us to seamlessly submit prior auth requests as part of our EHR ordering process. This is a solvable problem, and I’m enthusiastic that we can fix it. Jack Resneck, Jr, MD is Professor and ViceChair of Dermatology, UCSF School of Medicine and Chair, Board of Trustees, American Medical Association.




Can Tech Revolutionize Medicine?

UNLOCKING HEALTHCARE Stefano Bini, MD and Saul Marquez Do you think the solutions to unlock healthcare’s biggest problems already exist? If you answered no, then perhaps you are not looking beyond your current practice silo. If you answered yes, then perhaps you have ventured outside of your comfort zone and gotten a taste of what others outside of your specialty are doing to improve outcomes and results that could apply to your field within healthcare. If you’re looking for confirmation bias or evidence for what you already believe, this post is not for you. If you believe there are answers in collaborating and searching for breakthroughs beyond the norm… read on! Earlier today your two authors, Saul Marquez and Stefano Bini, were taping an episode for the Outcomes Rocket podcast ( The topic was the Digital Orthopedic Conference San Francisco ( and the Regenerative Orthopedic Conference San Francisco (www.ROCSF. health) which will be hosted back to back in January just before JPM along with the DOCSF Leadership Summit which is a oneday event focused on leading change in healthcare. During the interview Saul made an off the cuff but really interesting comment: “Healthcare is a like a combination lock,” he said, “one in which each element of the combination is hidden within a silo in healthcare. You just need to access each silo to get the numbers that open the lock”. Let’s riff on that idea real quick: DOCSF and ROCSF differ from other conferences because they are both laser focused on the last mile in healthcare. The last mile in healthcare, for any specialty, is where theory meets practice. DOCSF and ROCSF really concentrate on how to actually make stuff work in the musculoskeletal space; how to distill the operational aspects of these great new tools coming our way. When the rubber hits the road, these tools need to solve a problem for a specific end user, not “health care” as a whole. And solving that very specific problem for that very specific user means you have to focus on those needs. It is not as easy as showing up with a shiny new object and saying: “Here’s a new widget, it’s better than the last widget, go out and save the world!” Each stakeholder has a perspective on how that problem should be solved and what that widget should look like. That’s why at DOCSF and ROCSF the focus is on an integrated vertical: orthopedics (the study of the musculoskeletal system spanning from wellness to trauma surgery, from sports medicine to joint replacement surgery): the idea is to make the event practical. A good friend of ours who is a leader in his health specialty field shared a best practice that has helped him (and his various companies) succeed: attending conferences completely unrelated to his field. At these conferences, he has consistently found answers to the problems he’s been struggling with. We could not agree more. When we look beyond our silos, we often find the missing piece of our own puzzle. What does that mean for you? We believe that, whether or not you’re in orthopedics, and if you’re open to learning outside the box, “last mile” focused conferences like DOCSF and ROCSF (and podcasts like Outcomes WWW.SFMMS.ORG

Rocket) may just provide the last number you’ve been looking for to solve the combination and unlock the lock. And it goes beyond that. If you are trying to solve for a problem across silos, divisions or specialties within healthcare, you will need to find a formula that meets the needs of all the stakeholders if you want to have a shot at success. We argue that the solution for each of these stakeholders is like a unique number on the combination lock. It’s not until you have all the correct numbers lined up (ie: met the needs of all the stakeholders) that the lock can open and your solution meet with success. The challenge is getting the codes/numbers from all the stakeholders. This challenge may not be unique to healthcare, but healthcare is uniquely challenging. Our silos are deeper, stronger and better suited to insular thinking than most industries because the nature of healthcare is so conservative. Each silo is highly effective at mounting an immune response to change of any sort, particularly if the change is instigated from outside the silo and does not follow the codified (and intentionally slow) paths towards change. That’s why it is so very important to be proactive in your efforts to seek answers outside of your natural environment. This idea of the combo lock is a great visual. Bridging silos to share lock combination data between silos or cross-pollinating new ideas that will help unlock distant silos is exactly what we both try to do with the DOCSF and ROCSF conferences and the Outcomes Rocket podcast. By having senior leaders from industry, pharma, payers, providers, finance and technology all in one place discussing the same problems we can open up the silos. By interviewing them on the Outcomes Rocket we can come across really creative solutions. Dr. Bini is a Professor of Orthopedic Surgery specializing in hip and knee replacement at the University of California San Francisco, ranked in the top six departments in the USA. He is the Founder and Chair of the Digital Orthopaedics Conference (DOCSF) and The Regenerative Orthopedic Conference (ROCSF), both held in San Francisco.

Saul Marquez is an entrepreneur with over a decade of experience within the medical device sector working with companies like Stryker and Medtronic; his focus is working with provider systems and clinicians in the U.S. and internationally. As the host and founder of Outcomes Rocket, a healthcare podcast and healthcare consultancy, Saul breaks down the silos of healthcare by connecting innovators and health leaders across the globe to defeat the common enemy: inefficiency and bad outcomes.




Can Tech Revolutionize Medicine?


I contemplated smashing the monitor. I would not do that

today thanks to a much stronger Zen meditation practice in the years since, but at the time, the more relevant question was whether monitor smashing would evince my anger sufficiently enough. I decided against because our workroom was cramped and already messy enough. Our clinic had just rolled out a new EHR. I might have been the most emotional about it, but it was an open secret that my sentiments were broadly shared. Our clinic leadership had done their best complete with a cadre of IT support folks milling about, but the product itself was...less than ideal. It did not help my mood that this was just the least pleasant—although certainly not the least functional or least modern—of something like 12 different EHR-ish systems I had to learn on joining this clinic network. Turns out that, monitor smashing aside, my experience is not atypical among our profession these days. If happiness is the delta between expectation and reality, the EHR “revolution” of the last decade or so could hardly have generated less happiness among physicians. The first wave of EHRs was not for physicians. They are great for many processes of the medical ecosystem. Patients can see their data. Coding and billing is far easier. Research and quality 10


improvement can be far more efficient without digging through stacks of paper charts. This first wave technology just did not have much to offer us physicians. This phenomenon is standard procedure in the broad sweep of technological change, but it has been some time since our profession has been swept up in it. The printing press was a boon for our forebears, but it did little for the farmers of the time. Internal combustion, with its tractors and eventually combines, was a revolution for farmers but did little for accountants. Then came the computerized spreadsheet—what a boon no longer to have to add up all those transactions by hand! Our generation of physicians has had the misfortune of practicing in the trough right before the great wave of technology that really will improve both our work and our relationships with patients. Fortunately, the second wave is underway right now. One obvious area for technological improvement is data entry. We all hate looking at a computer screen instead of the patient in front of us, and spending hours charting after a full day in clinic. The first wave EHRs had no answer for this, but the second wave has this solved. Anyone who has used Amazon’s Alexa or worked with a human scribe can imagine the scene. There’s a tiny microphone on our white coat’s lapel. Smart software listens to the patient visit and transcribes in real time. On concluding the visit, we can “dictate” technical jargon and orders in a matter of seconds. Also ripe for the second wave is smart interpretation. When a patient’s hemoglobin A1c comes back at 6.2 from 8.8 three months ago in a first wave EHR, the software says...nothing. It sits there with a blinking cursor waiting for me to type “A1c down by 30% from baseline - wonderful!” That is plain silly especially when the assessment is so obvious. Here at Virta, and surely in many other systems, we are already using smart systems to template text for both documentation and patient communication automatically. We have even gone a step further by building standard of care algorithms, such as the ASCVD risk calculator and accompanying medication recommendations directly into our EHR data. Computers are way better than humans at plugging discrete data into complex equations and flow charts. It lets doctors focus on the human touch. Perhaps the most exciting area for second wave innovation is in what I might call data curation. Take a primary care provider with an inbox of screening labs. First wave EHRs sort them... stupidly - by patient name or date received. The result is that the few important results are buried under a mountain of normal CBCs and lipid panels. The central feature of second wave technologies is the ability to sort that mountain smartly—figure WWW.SFMMS.ORG

THANK YOU TO OUR MEMBERS out which data are important, put them at the top and allow the rest to be safely dismissed with a click. In addition to clearing out piles of drudgery, this will enable us to treat more patients but do so more safely. While even the most diligent human will, at some point, miss a key datum in the mountain of banality, technology can make such sorting much safer and more efficient. We have built many tools like this at Virta, and I cannot wait until they arrive at my other gig in the Stanford NICU. Let the software handle the piles of normal TPN labs and low risk bilirubins, so I can spend my time on the critical blood gases. Take heart, colleagues. First wave EHRs were not for us, but the technology that makes our lives easier is coming. A graduate of Stanford’s MD & MBA programs and UCSF’s PLUS residency, Michael Scahill is now Medical Director at Virta Health and an instructor at Stanford’s Department of Pediatrics.


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Can Tech Revolutionize Medicine?

THE DIGITIZATION OF HEALTH CARE Disruptive and/or Wonderful? Robert Wachter, MD, Interviewed by Kimberly Newell Green, MD The digitization of health care has been in some ways a rocky experience for many physicians: In many ways digital health has been “just disruptive” rather than “disruptive and wonderful” so far. You have said before that you wrote your book “A Digital Doctor” in part to accelerate the time in which we would move towards the “wonderful.” Your initial estimates were, if I’m remembering right, that it would take 20-25 years for digital health to become fully mature in health care. Where do you think we are now on this spectrum? Wachter: I just came out of a conversation with UCSF’s senior leadership talking about our digital strategy. We were actually raising exactly this issue—how long will it take. In some ways the question is: When did that clock start? For the US healthcare system I start that clock around 2012, which is when more than 50% of hospitals had electronic health records, and about the same percentage of doctors. Locally, Kaiser first implemented its EHR in the early 2000s and UCSF a few years after that and the VA about 5 years before any of us. So different organizations have had different trajectories. But let's start the clock when as an overall industry we went from majority paper to majority digital. The reason that’s important is that the literature supports this notion of the “productivity paradox”. It takes some time before organizations can remodel themselves to take advantage of digital capabilities. That’s partly because legacy organizations are rarely the leaders here: They are relatively fixed in the way they do things. It’s also because the initial technologies tend to stink. They are not the ones you want to end up with, but they are the ones that are available out of the gate. And also, there are a whole lot of entrenched interests who either don't see the value of change or actively fight it. The average time it takes an industry to improve its productivity with digitization is 10 years, so we're at least halfway there. But in healthcare I’m guessing we’re looking at more like 20 years. And the reasons are several. First, failing fast is attractive if you're opening a restaurant, but is unattractive if it's your mother’s health. And displacing the existing legacy organizations and its people is not that hard when they're called Yellow Cab and taxi drivers, but it's pretty hard when they're called UCSF and they are doctors. I think 15 to 20 years from now is the time that we will see true transformation. Now you do see leading organizations doing things differently. I wrote the book about four years ago. I had a very hopeful futuristic chapter at the end. And people came up to me and said “I loved your book, but who wrote that last chapter—it’s far too optimistic.” One of the fun parts of my book research was that at the end of the year of listening to a hundred different people I could list the markers of what's working. For example, more



than 50% of touches with patients in KP now are digital. That was inconceivable 10 years ago. Some telemedicine companies are succeeding. We're beginning to see computerized clinical decision support that is actually meaningful. Another important trend is that now you see the entry of an enormous amount of venture capital into digital health, and every major digital tech company and every big venture capital company in the universe is saying, “Now is the time for health care. We're all in.” That is really important, because they will drive much of the change. Neither Google nor Amazon, Apple or IBM totally understand the industry or the problems. But they are are a lot more realistic than they were 10 years ago when they tried their hand in health care and failed. And they're in it for the duration now. They’re in it because they know that there’s a task that they could not have done 10 years ago which is now done: All the data is in the EMR. So I think that the degree to which we now see an entry of capital and human talent entering our world and helping us do things better, safer, cheaper, it's almost inconceivable that they won't succeed, eventually. I agree and I’m very glad to hear you say that. It seems to me that the changes in AI, and specifically machine learning just in the past three to five years have the capacity to accelerate the pace of change in a really positive way, if the right people are learning how to ask the right questions. Wachter: That of course is the trick. The science of AI, and the cost of doing it: both have trended in the right direction. The CEO of the UCSF’s health system asked me: “Alright, all this magical stuff is out there. What are the obstacles to using it to improve the way we do operations, scheduling etc?” And the answer is: some of them are truly technical problems and we WWW.SFMMS.ORG

have to invest in technical solutions in the right way. But in some cases—unless you are completely taking the things out of the hands of humans—we still have to figure out: how does this sync up with the people, and the workflow, and the humans and the way that they think. And we have to ask: is this tool answering the right questions?

There's that sort of operational work of medicine that's not that sexy, like billing or scheduling, and as you know we're way behind most of the consumer industries in this. And then there are the clinical questions that as doctors we get excited about. It feels to me that the operations part of health care delivery is really ripe for change, in terms of what the technology is doing now in other industries, and I'm curious if you have any thoughts about this. Have you seen anything that's exciting or problems that you wish someone was would solve quickly on the operation side?

Wachter: The stuff I see as a clinician and chair of a big department are fairly patient-facing. Today in this building [UCSF Medical Center] we have about 600 patients, and the systems by which we figure out where they should be, how they move through the system, and how we get them the things that they need at the right time and at the lowest cost are pretty rudimentary. It feels like we can benefit from better information and analytics that allow us to deploy our capital better or allows things to be done by technology where right now we throw FTEs at them. However, so much of medicine and its expenses and quality problems and variations and equity problems really do happen where you and I work: in front of the patient. The decision you make is different than the one I would make, and the literature might say that the decision you made is better than the one I made. Now technology could allow us to measure that and deliver information to me that will help me practice better and cheaper. That all sounds great until you actually do it because you're getting in the way of my autonomy. That's the hard stuff. As soon as you begin tackling that you are encroaching in a world where physicians have enjoyed nearly unfettered autonomy. And that’s where you have the biggest sociocultural battles.

Back to clinical decision support (CDS) itself: At a recent conference you said something that we haven't figured out is how to do CDS without AI and it's not clear that AI will make it better. But I really believe that we should be able to help improve our care with some computer-based support sooner rather than later. Atul Gawande mentions in one of his books that the amount of knowledge we have compared to the 1970s or 80s when doctors could know everything there was to know about medicine has grown exponentially. I felt this even as a medical student and was eager to have support to help me do my job better. As physicians, we often don't admit this to ourselves: that we can't actually know all of the information available to care of patients, and that we need help. I would like to have clinical decision support and then layer my wisdom and experience on top of it. I wonder if you've seen anything helpful in this arena.


Wachter: I I think your answer may be colored by your years at Kaiser. As an organization, partly because of the way the money comes in and out and partly because of some wise decisions about the way you organized yourself, there is general cultural buy-in that, as a system, we are trying to figure out a way to deliver the best care at the lowest cost and any tool that helps you do that is a good thing. I think that is still a lift for much of the rest of medicine. In theory, who can be against the idea that the computer will help guide me to a better, safer, and less expensive decision? Until in real life the computer annoys you because it's pinging too much. So there’s a general issue about the way we interact with these damn machines and we’ve not yet figured out how all that works in a way that’s manageable. But then there's a deeper and more challenging issue around intellectual autonomy. Sometimes the computer’s answer is different than what I think is the right thing or what I've done for the last 30 years that seems to have worked pretty well for me. I saw this in the early days of the quality field. In quality we looked at variations and said “that’s bad—not all these answers can be right.” And I’d meet with a group of well-meaning physicians and they’d say: “You know, I can see why standardization would be good. If everyone would just agree to do it my way we’d be cool.” If a decision support tool confirms your bias about the things you feel strongly about, that’s fine. In some way decision support is code for is giving someone else—Medicare, Aetna, Kaiser, your colleague—the ability to give you information about how to do your job. You might start off with a benign framework: “it helps you practice better and you can choose to use it or not use it.” I think most people appreciate that over time, if the organization is being held accountable for outcomes and if you are practicing in a non-evidence-based way, someone is going to show you your dots against the curve and ask: “why are you an outlier?” And eventually those outlier options are going to be greyed out on your screen. So it’s a natural progression as an organization: as the industry goes from artisan—everybody does it their own way—to something that's much more systematized, there is less autonomy. And generally high-paid high performing professionals don't love that. Some of the degree to which doctors will accept this hinges on: is the organization or your practice under existential pressure to deliver better care and better outcomes at a lower cost? Physicians are resistant to change partly because their unemployment rate is 0.2%. And despite the fact that we talk about all the threats to health care, we've been pretty well shielded from the kind of existential threats that cause people to try very different ways of doing their work. We may see this ourselves if payment rates go down, or if new entrants come into the field and we realize: if we don't do this better, safer, and cheaper, we're going to go out of business. But it’s hard to picture a new company coming in and taking over for what a 700-bed academic teaching hospital does today. But for what a primary care practice does? You see One Medical, you see Forward, you see telemedicine companies, you see the tech-enabled companies built from the ground up that don't have a legacy organization they have to battle beginning to encroach in the spaces that are continued on page 14




Can Tech Revolutionize Medicine? easy to encroach upon. It largely starts in the consumer side, and then moves into more traditional medicine. I agree with that and that’s why I think it’s vital that we not only anticipate but also participate in the transformation of health care so that we can make sure the new systems that evolve reflect our values and allow us to continue providing care to our patients in the best way. So I wonder if the actual technology side of doing clinical decision support, where are we there? Do we have algorithms to support CDS that are good? Wachter: Not many. My son works for the Atlanta Braves in baseball analytics. The sophistication of what he can tell you from data with two keystrokes compared to what I can tell you running a hundred and fifty bed medical service in one of the greatest teaching hospitals in the universe is just night and day. He can tell you this guy can't hit an outside curveball on Tuesday nights when the wind is out of the southwest. Whereas our big success story is a sepsis alert that's wrong 25% of the time and fires on 3-4 variables, like fever, white count and lactate. Wow. And you think about what the tech companies can do for mining their data, and how they constantly refine their products and their interface with their customers and how little of that we do. We just have to get to substantially better. If healthcare were Google or Amazon, every time you made a complex decision the system would be scanning to see what the outcomes of that decision were, and feed that information back into the system so the next time you or someone like you had to make a similar decision, the recommendation would change. Theoretically, our data could be monitored and mined and ultimately fed back into the system to tell us: the next time that physician makes the same decision, here is the decision support that either will force you to do the right thing, or nudge you in a behavioral economics way to do the right thing or at least give you feedback that you're doing something that seems a little odd or different. The level of decision support we have now is totally rigid, an algorithm or not even an algorithm. It says: “if the patient has X I'm going to fire an alert.” But it's unable to learn and improve over time or even to test itself and see whether it's working. And then the way it's delivered is in a way where no one has really



thought about the user interface. If you think about the ways an app on your iPhone get you to be delighted to lose weight, and how strategically they have designed these things to get you to do the things they want you to do and be happy about it…. No thought has been given to any of those things in healthcare. We have so very far to go. Another problem is that the core competencies you’d like your EMR company to have today—using data, artificial intelligence, clinical decision support, data visualization, behavioral economics—none of those were on their list of core competencies 10 years ago. So maybe they'll remodel themselves to begin helping us do these things, but the tool they built wasn't one that was designed to do any of that stuff, and it's relatively inflexible in its ability to integrate with new tools that are now being developed. We're all stuck with this fairly clunky enterprise system that’s relatively inflexible, whereas a lot of the innovation is going to be developed by other companies, building tools and apps that plug and play into the existing EHR system very well.

I was wondering if you have a wishlist: what are your top three wishes for people working in this arena? Wachter: We haven’t talked about physician burnout and joy. When I wrote my book it was just emerging as an issue. But now the degree to which it's on the radar system of healthcare systems, who are looking at Net Promoter Scores and Gallup surveys of their doctors, is impressive. When the physicians were an infinitely expansile form of human capital, who just kind of plugged along with their work, nobody paid a lot of attention to them. But that’s changed, and the fact that it’s on health systems’ radar screens is a hopefuly trend. Why does the health system care about physicians’ happiness? Partly it’s because they bring in the patients. And partly because, increasingly, they work for the health system. When the physicians were just free range chickens doing their own thing on the outside, the degree to which a health care system leader cared about how happy they were was attenuated, as long as they were bringing patients through the doors. Now that they work for me, it's a very different relationship. It's another feature in which Kaiser is ahead. But that degree of integration is also natural for an academic health system like ours where all the docs work for the system. In terms of killer apps: The first one I think is a digital scribe. And to me that's because it's sort of the most obvious and glaring thing that went completely off the rails here. When I give talks I show that picture that was in JAMA a few years ago, a crayon drawing by a seven-year old who went to visit the pediatrician. In the picture, the doctor is in the corner, facing away from the patient and her mom, typing into the computer. It’s so egregious and heartbreaking. If the technology could create an environment where I just had a conversation with the patient and the documentation happened as a secondary effect of that, that takes a huge pain point off the table. A second one is something I spend a lot of time thinking about. It always strikes me, I'm a generalist, a hospitalist. For every patient I see there are 50 specialists who know more about every problem the patient may have than I do, but I know more about all of it than they do. The only mechanism for me to get their help for the individual problems I’m taking care of is WWW.SFMMS.ORG

this thing called a consult. And that’s stupid. It's this incredible binary decision. I either get nothing, or I get a full-on consult when someone has to come and spend an hour doing their thing. Why is that? Because a formal consult is the only billable event. We haven't figured out, in a scalable way, how to take advantage of the expertise of specialists in the day-to-day care of complex patients, whether in the outpatient or inpatient practice. I think there's got to be a technology that helps create something that has much more nuance to it. A way of encoding the expertise of specialists and delivering it to generalists and maybe ultimately patients and families, somewhere between the binary options of nothing or, a full consult. I don't know what that looks like exactly but that, to me, is really exciting if we can get that right. Third is maybe a version of that. When I talk to the docs here about how unhappy they are it's partly because they go home, they have dinner with family, and then from seven until 11 at night they’re online again. So that’s partly documentation and may be helped if we get the scribe thing. But it's partly because we have enabled 24-hour connectivity without coming up with a business model to support it. If we were smart, maybe we would have been like the lawyers and charged every six minutes. But we weren't. So what does the system look like that does that? Whether it's the problem of managing patient emails at night, or the new problem of every patient now having sensors on an Apple watch that can send streaming data? If all that data goes directly to primary care doctors—you know better than I do—we're dead in about two minutes. What does the system look like that is helping patients in the middle of the night, is capturing data from patients while they're living their lives and helps manage this digital tsunami? That middle layer has to be created by somebody, and obviously tech is going to be part of it because none of this is doable without algorithms, but some of this will just have to be done by people. It just can't be the primary care docs without a lot of new kinds of help. I’m glad you brought up physician wellness because I care a great deal about that. What I used to always say is that when physician wellness is at the center of operational decisions then things will go better, because we have to be well to do our job well. And as you say the good news is that it sounds like that’s happening in organizations now. But what I’d like to know is: where do you find your joy in medicine these days? Wachter: I get massive joy when I do clinical work but I only do it for a month every year. For me it's therapy. Other than that I spend my life in meetings and dealing with budgets and trying to solve hard problems. To me, it brings me incredible joy to go out there and take care of really sick people with the kinds of trainees we have here. What I do think that may be more relevant to the more general question is: I think this is an incredibly exciting time to be in medicine because I think we're pivoting from one way of doing our work to a completely different way of doing our work. While it's an extraordinarily uncomfortable and bumpy transition, at the end of the day I don't see a way that we have not created for a system that makes care better and makes the WWW.SFMMS.ORG

experience of providers better. Part of what's so unpleasant about today's medicine is the amount of time that I'm doing stuff that's just stupid, that adds no value to patients. Whether it's calling the insurance company for authorization or feeding the electronic medical record. All the crap we all have to do that we not only didn't train for or go into the business to do, but it's also just a massive waste of our time and talent. But now we’re paying attention to those issues, innovating on them, trying to train people to become a new generation of physicians who work on how to make the system better. To me that's infinitely exciting and energizing. Recognizing that some of the talent mix that we need to do this work lives in a place like ours, but some of it lives in companies. We have to figure out ways of working collaboratively with them to get these problems solved. And those kinds of relationships are really fun too. So I'm having a blast.

Robert M. Wachter, MD is Professor and Chair of the Department of Medicine at UCSF. Wachter is author of 250 articles and 6 books. He coined the term “hospitalist” in 1996 and is often considered the “father” of the hospitalist field. He is past president of the Society of Hospital Medicine and past chair of the American Board of Internal Medicine. In the safety and quality arenas, he edits the U.S. government’s leading website on patient safety and has written two books on the subject. In 2015, Modern Healthcare magazine ranked him as the most influential physician-executive in the U.S.; he has been on the 50 most influential list for each of the past 11 years. He has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.




Can Tech Revolutionize Medicine?

THE PAST AND PRESENT FUTURE IN MEDICAL TECHNOLOGY Graham Walker, MD Biking home from a long shift in the emergency department one summer evening, a car swerved and sped past me on the street. “What a maniac,” I muttered to the cyclist next to me. Moments later, I noted a small crowd gathering at an intersection two blocks ahead. I raced up to see the commotion: a young man had been struck by the car. He’d sustained a bad head injury, but was breathing. But not moving nor responding. My baby blue scrubs nominating me as the guy in charge, I told a bystander to call 911, and transformed into doctor mode. The emergency medicine koan “Airway-Breathing-Circulation, IV-O2-Monitor” leapt into my mind, and then immediately failed. Besides positioning his airway, feeling for a pulse, and shining my cellphone light at his pupils, I was pretty useless. No IV, no monitor. No stethoscope. No intubation tray. I waited, and waited, and waited, and finally EMS arrived with everything I actually needed to be a doctor (medical equipment), and scooped him up into their rig, rushing him to San Francisco General. It was hard to acknowledge, but I was nothing without my gear. When I was asked to write a column about medicine and technology, I thought about all the cool stuff that Star Trek nerds like myself drool over: tricorders, nanobots, androids. But you can learn about those on a CBS Sunday Morning piece, or a Youtube video, or a Black Mirror episode binge. Instead, I’d like to look at how technology—in all its shapes and forms—has and will change what it means to be a physician. I was taught in residency that physicians exist because we can do three things: we can diagnose disease, we can prognosticate disease, and we can treat it. Over my years, however, I think there’s two more functions that we serve, regardless of disease state or symptom. First, we can alleviate suffering. Second, and certainly most forgotten, is the value of the therapeutic relationship itself. And it turns out that technology is the driving force that has changed all five of these pieces of doctoring. Don’t get me wrong: knowledge has given technology a run for its money when it comes to impacting medicine. But to be blunt, humans are pretty limited with what we can figure out based on observation, experience, and anatomy class alone. (Hats off to John Snow for mapping the London cholera outbreak, but even Pasteur and Koch needed a microscope.) Since the 1850s,



technological advancements have been the source of progress in medical care, with physicians’ roles changing as they have embraced the technology that has come into practice. • Stethoscopes and x-rays allowed us to diagnose and prognose disease states better; • Surgical anesthetics and techniques and antibiotics revolutionized our ability to treat patients; • Opiates, other drugs and even psychotherapy allowed us to alleviate suffering more effectively. It’s no coincidence that “modern medicine” started to organize around the turn of the last century, as these technologies significantly improved our ability to diagnose, prognose, treat, and alleviate suffering. And with the widespread adoption of these technologies, not only did physicians’ practices change, but so did their role in society. Physicians went from tradesmen and bloodletters to trusted diagnosticians, prescribers, and surgeons. But there’s always a downside. In medicine, it’s the overuse of and over-reliance on our technology. In medical economics, this is known as the “If you build it, they will come” problem; you buy a new MRI machine? Doctors start ordering more MRIs. You build a new pediatric ED? Your pediatric volume goes up. In almost every introduction of new technology, we tend to overuse it, with numerous consequences. Too much imaging? Radiation risk and unnecessary studies, when the patient would have gotten better on her own. Too many antibiotics? Resistant bacteria. Too many opiates? The worst public health crisis since HIV and the longest sustained decline in life expectancy in 100 years. And how do these over-usages of technology affect physicians? More than anything, they affect our forgotten, fifth function: the doctor-patient relationship. Ever prescribed some Norco or a Z-Pak when you didn’t think it was the right thing to do? Ever ordered the CT when you didn’t think the patient really needed it? When we rely on technologies to “do the doctoring for us,” not only do we harm the patient, but we also chip away at the trust in the relationship with them. The patient may think, “Wow, I’m glad I advocated for myself, I really did need those antibiotics,” and asks for them the next time. The doctor may think, “I don’t have time to argue about this, I’m never going to convince him; I’ll just order the scan.” When we use technology in place of an honest, sincere, and empathetic evaluation of a patient, both sides of the equation typically lose. (Please don’t take this as shame nor blame; as an emergency physician, I’m certainly guilty, often weighing the additional constraint that pushes me the hardest: time.) That brings us to today. Walk into any office or hospital and ask to see the sights and hear the sounds of “medicine being practiced,” and you’ll be taken to an office, not a bedside. You’ll see a weary-eyed clinician clicking between patients and clacketyWWW.SFMMS.ORG

clacking away at a keyboard. Welcome, electronic health record. Following the same framework, it’s hard to argue that the EHR hasn’t improved our ability to diagnose, prognose, treat, and alleviate suffering. We can (literally) read each others’ notes; we can order medications and studies rapidly; we can even communicate with each other and our patients electronically. But the price? The doctor-patient relationship, yet again. As we now use the EHR for everything in medicine, it’s even easier to order the unnecessary study, only communicate with the patient by text, or miss important changes in their health because we’re remote, or rushed, or paying attention to the virtual patient, not the one in front of us. The EHR has brought benefit, but not without harm. And yet, I have hope. Despite all the frustrations of desktop medicine—the poor usability, the burnout, the hours playing expensive secretary— there are many glimmers of said hope. First, the EHR systems of today are certainly better than they were just 10 years ago (if you can remember that long ago). Second, physicians are learning more about how to use them in conjunction with the patient visit, and include the EHR in the visit, as opposed to focusing on the computer screen. And arguably most importantly, our Department of Health and Human Services is finally starting to acknowledge the burden they have placed on physicians, and plans to do something about it. Just last week (November 28, 2018), HHS released a draft of a position paper entitled Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs. The 74-page paper finally acknowledges (and even specifically names) “note bloat” as a major issue affecting clinicians, and even recognizes that HHS is responsible for onerous documentation requirements (ten point review of systems, etc) in order to bill for medicallycomplex services. It goes on to report that this level of mandatory documentation is “out of sync with current medical practice” and that clinicians: …frequently use the EHR to enter excessive or overly detailed documentation such as irrelevant details about patient history, unaffected systems, or unrelated physical exam elements. This clutters the EHR for any particular patient and makes it difficult to find pertinent information in the EHR. The paper notes that "These challenges affect productivity, increase organizational cost, and detract from patient focus, resulting in negative experiences using health IT.” The authors go on to acknowledge that HHS has failed to improve the laborious process of “prior authorization” as well. Importantly, the paper even comments on payment, admitting that much of EHR frustration is driven by reimbursement. It recommends allowing clinicians to bill based on the current framework, based on medical complexity, or even based on face-to-face time spent with the patient. Finally, HHS reports its concerns with “alert fatigue” and poor user interfaces, and the burden of documenting “quality measurements.” It recommends that quality measures be modified to fit naturally within the clinician workflow, so less time would be spent button mashing and checkbox-checking. Clearly, someone at the Department of Health and Human Services is actually listening (and/or practicing medicine themselves). I believe that our over-usage of the EHR is already turning WWW.SFMMS.ORG

the tide as we develop better desktop medicine tools that work for us, instead of us working for the tools. What may the future hold? I’m, again, an optimist. With over 450 clinical scores on MDCalc—and new, already-validated scores being published every week—it is extremely clear that physicians are hungry to use data and evidence to influence and improve their practice. New EHR standards are allowing us to import the scores directly into the EHR, pre-populating them with data from the medical record and allowing faster, more accurate results for clinicians. “Big Data” (massive data sets from millions of patient encounters) will likely allow us to fine-tune existing algorithms and predictive scores and develop newer ones. It’s most likely to me that these prognostic or diagnostic Big Data algorithms will be combined with clinical and laboratory values to improve diagnostic accuracy further; the human body has only so many proteins it can spill during a myocardial infarction, but if we combine an indeterminant troponin value with a subtle EKG finding and the experience of 150,000 other 38 year-old men with “indigestion,” we’ll be able to find the needle in the haystack, and quickly discharge the rest of the hay. The same might be true of equivocal imaging studies, exposing fewer patients to unnecessary risk of biopsy or surgery. Physicians will have to become masters of the electronic health record (sorry, Luddite, MD), and Soothesayers of Big Patient Data, just as we have gone from mastering the stethoscope and are still mastering the ultrasound probe. (The potential downside? We’ll lose more of our clinical acumen, and not pull the trigger on acting on an obvious case, because we entered the data wrong or the computer isn’t sure what to do.) Humans — at least until I’m gone — will want a person to explain their symptoms and interpret their data. They’ll want the original function we started with centuries ago: the doctor sitting across from the patient telling them they’re going to be okay. The alternative? A computer’s cold, sterile print out:


Dr. Graham Walker received his medical degree from the Stanford University School of Medicine in 2008, and then went on to complete his residency in Emergency Medicine at St. Luke’s-Roosevelt Hospital Center in New York City. He returned to San Francisco in 2011, completing a fellowship back at Stanford in Simulation Medicine, and since 2012 has been practicing with Kaiser Permanente/TPMG in San Francisco. He is the Assistant Physician in Chief for Technology at the Kaiser Permanente-San Francisco Medical Center and the former assistant chief of the emergency department there. He is the creator of MDCalc and theNNT, two online evidence-based medical resources, and welcomes your comments and engagement @grahamwalker on Twitter.




Can Tech Revolutionize Medicine?

TO SOLVE A COMPLEX HEALTHCARE CHALLENGE, FOCUS ON YOUR MISSION Larry Ozeran, MD What is your mission? Do you know your mission, personally or professionally? My personal mission is to do well by doing good. My corporate mission is to promote optimal computer use in clinical practice. Your mission matters when used in day-to-day choices as well as strategic initiatives. My personal mission guides me every day and helps me make difficult decisions, such as where to practice when I finished surgical training. Rather than staying in Beverly Hills after finishing residency, I moved to a rural community in Northern California because they had a desperate need for surgeons. My income was lower but my scope of practice expanded to fill the void of cardiac, oncologic, and thoracic surgeons. I lived a mission-driven practice I loved.

How does a mission-driven process help manage more complex decisions?

When evaluating a complex challenge, first consider your mission, then your values, objectives, and goals. Create a needs assessment, a laundry list of what you need to meet your objectives and goals while honoring your values and focusing on your mission. Create a gap analysis that maps a path from where you are to where you want to be. Together, these efforts will define the products and services you need to be mission-driven.

Mission defines the context for managing your challenge.

How might this work? Imagine it is 2011 and your health system is looking fearfully at ARRA legislation that included $38 billion in incentive payments for adoption of Electronic Health Records (EHRs) and penalties of up to 3% of Medicare revenues starting in 2017 if you don’t adopt a certified EHR. To approach this complex issue focused on mission, first ask “How can we integrate this new requirement into our mission-driven activities?” In this story, your mission is some form of “We value our patients and give them the best care at an affordable price.” Your mission says that you value 3 things: 1) patients, 2) quality of care, and 3) cost. In my 2011 HIMSS podcast [ episode-34-impact-arra-incentives-and-ehr-adoption], I focused on cost. I encouraged healthcare leaders to apply 18


for the incentive payments if they were already on the path to EHR adoption. Otherwise, I urged careful consideration of the Return on Investment (ROI) before automatically responding to the legislation by adopting an EHR. I think that few healthcare leaders and organizations fully considered how the costs of the Meaningful Use program, both financial and human, might impact their mission. Not only were huge sums of money spent, clinical workflow was seriously modified. In some cases patients were harmed, and in some cases financial ruin befell the organization. One hospital was reportedly bankrupted by their EHR purchase. A focus on mission might have avoided these serious negative outcomes. Continuing the example, let us consider an imaginary heath health system that is focused on its mission. In 2010, Focused Health: • generated $6 billion in annual revenue,

• collected 30% of its revenue from Medicare (though 50% of its patients were Medicare beneficiaries), and

• faced a penalty of 3% of Medicare revenue starting in 2017 for not implementing an EHR.

The Focused Health mission valued patients, quality and cost. In the context of its mission, its leadership created a broadly representative multi-stakeholder team to develop a needs assessment and gap analysis. The team reported that there were EHRs with beneficial features, but no existing EHR would meet all of their needs and major workarounds would be needed. What should they do? Before describing what Focused Health did, recall that an EHR is a tool. Workarounds are an indicator that either the wrong tool has been selected or the tool is being used in the wrong way. Imagine that you need to insert a nail into wood and the only tools available are a dictionary and a small, flimsy piece of sheet metal. What do you do? You can create a workaround, wrapping the sheet metal around the book. You can search for more traditional tools. You can step back and ask, do we need to insert the nail? Without the context for this generic need, options are limited. WWW.SFMMS.ORG

Mission creates context. Focused Health concluded that EHRs were unlike most innovative technology. They did not make clinical processes better, faster or cheaper (perhaps explaining why federal incentives and penalties were required to promote sales). Focused Health assessed the ROI of EHR adoption in light of its mission. It decided to pay the Medicare penalty and find a better technology tool to meet its mission than an EHR. Focused Health spent $20 million on a bar coding system that created standardized sheets of paper for each patient visit with standardized clinical intake sections where clinicians could write by hand or dictate by section. Focused Health standardized and encoded the paper form to enable a smooth transition to an EHR when it eventually finds an EHR that meets its mission-driven needs. The sheets were scanned into a data repository including an image of each section or the transcribed dictation of the section, enabling easy digital record storage and retrieval. As a result, Focused Health:

• did not spend $2 billion on an EHR,

• did not spend hundreds of millions of dollars on consulting fees for implementation,

• did not lose hundreds of millions of dollars of revenue during clinician training periods,

• is not now spending $350 million in annual EHR license fees, • deployed money saved to improve existing care systems that support its mission,

• focused on the existing clinical workflow, limiting changes to how clinicians saw patients, • did not have frustrated physicians or other clinicians,

• did not create technical workarounds that harmed patients,

• is not completing and filing Meaningful Use reports,

• does not currently have a physician burnout problem.

Its $54 million annual Medicare penalty (6,000,000,000 x 30% x 3%) is just barely 15% of what its EHR maintenance fee would have been. Focused Health patients see doctors faceto-face and both are happy with technology enhanced paper records. Focused Health remains open to EHR adoption and is positioned for a straightforward data and process migration when adoption occurs in the future. The message is not, EHRs are bad. This story is not fuel to return to paper charts. Having programmed an EHR myself in 1990, I know EHRs can improve healthcare, but each EHR is a tool suitable to specific purposes that may or may not match your needs. Identification of the right technology tool requires an effective process that uses mission and values to drive identification of those needs. The message is: learn from our shared history to avoid repeating process mistakes. Always be guided by your mission. Every healthcare organization had the same information that Focused Health did. Every healthcare organization could have looked critically at the legislation and squared it with its corporate mission. Why are there few (if any) real life examples of a Focused Health? WWW.SFMMS.ORG

Perhaps the organizational leaders presumed adoption was preordained and failed to think critically about the problem with a focus on their mission. Perhaps they were misled by technology successes in other industries. Perhaps insight from colleagues and staff in a way that focused on supporting the organization’s mission was needed (as opposed to simply dissenting to maintain the status quo). If you see your organization moving down a path that has not been critically assessed based on mission, values, goals, resources, and processes, be willing to champion the mission. Remind, cajole, and ask your leadership peers to focus on what matters most. The mission of the organization serves a purpose, to guide the organization, both strategically and daily. If your organization is traveling down a technology adoption path that is contrary to its mission, or has failed to consider its mission, remind leadership of our shared experience with EHRs. Remind leadership that losing sight of what matters most can have dire consequences. Do what you can to focus the options on those that support your mission. If you feel as though you have no power to change the process, work through your physician colleagues in leadership. Think about elections and how a single vote can change the outcome. The views expressed by one person might spark insights that lead an organization down a different path. Speak up. It is hard work, especially starting as the lone voice. If no one steps up to join you, work through your network to find allies and promote mission-driven efforts. You can make a difference in the direction of your entire organization. You can remind leadership that the best outcomes occur when your mission is your guide. Good luck!

Dr. Larry Ozeran has served as a programmer, software developer, trauma surgeon, healthcare organizational leader, and health policy advisor. During 18 years in the CMA House of Delegates, the House adopted several of his IT resolutions, including formation of the Information Technology Committee. As President of Clinical Informatics, Inc., Dr. Ozeran provides strategic advice and professional support to healthcare organizations, government agencies, and software developers.




Can Tech Revolutionize Medicine?

TELEMEDICINE: A HEALTHY “SOCIAL MEDIA” James Wantuck, MD How many of your closest family members do you never call and never text, and then visit with only in person? I suspect not very many, except for those close family members you don’t want to be so close with! My point is that relationships are hard to maintain with infrequent contact, especially in today’s connected world. Now, how many of your patients will you see only once a year, never calling and never texting? What makes our world different with patients—why don’t we connect with them more often? Reimbursement and workflow are the culprits, I suspect. There is a not-so-new technology that removes these barriers and enables us to form stronger bonds with our patients: the internet. Big surprise, but there is no doubt it is going to indelibly alter the practice of medicine, as it has every other aspect of our lives. I intend to convince you that this will happen in three ways: first, it will give patients options in where they get their care; second, it will create a more human connection between us and our patients; and third, it will improve the quality of the care we are providing. I will argue that despite telemedicine’s perceived limitations, the practice of medicine will be better for both patients and physicians with virtual-first medicine. Healthcare is local. Large health systems often dominate major metropolitan areas. Rural areas may have few or no physicians at all. In theory, getting all your care in one place should lead to more coordinated care; in practice it often means the local monopoly leads to higher prices and less focus on good patient service. Enter telehealth: suddenly you can now reach a world-class physician nearly immediately and from the comfort of your home. The local doctor who can’t get you in for three weeks or whose office can’t even answer their phone (let alone allow you to schedule online) isn’t the only option. For mental health care and specialists, a patient’s choices are increased by an order of magnitude and care is available immediately. The town without a psychiatrist no longer exists: there is an app for that. The choice and convenience we demand in every other part of our lives is finally coming to healthcare. Physicians wonder if too much choice can impede quality care. This is an argument against access: give people immediate access to physicians and they won’t form a relationship with any particular one. By increasing autonomy you sacrifice quality they say—it is too easy to get a second or third opinion until you get



the one you want. With a poorly implemented telemedicine models, this is true. However, the traditional care model is worse: you will see your physicians for fifteen minutes once or perhaps twice a year, while we all know that health is a daily concern for our patients that is ever present in their lives. How can you possibly treat someone’s blood pressure with a measurement taken once a year in your clinic? This is not the level of care possible with the technology available to us today. Second, physicians ask how are we to build relationships virtually, without nary an office visit. With virtual care delivered via telemedicine, physicians can form real, close, more human relationships with patients. A few video visits, with several text-based conversations interspersed, combined with a heavy dose of continuous monitoring and in-home diagnostics makes for a relationship unparalleled in the clinic. Talking to your patients a dozen times a year, even briefly by text, is what will establish lasting trust and a more rewarding connection for both parties. An important aspect of any model is to be conscious that for physicians, this communication comes at a cost and is at risk of invading their time outside of the office. Getting a text from a patient at 9 p.m. wouldn’t be as welcome as one from your aunt. With the proper communications system, appropriate triage, and reimbursement these risks can be mitigated. Every other relationship you have in your life is enhanced by text, email, and virtual interaction—why should medicine be different? The key is finding ways to efficiently and accurately communicate medical information electronically, and to do so in a way that ensures reimbursement and reduces risk. Payers are starting to get on board: many private payers cover some forms of telemedicine, and government payers have long done so. Medicare will, in 2019, start paying for “virtual checkins”, those short conversations that take place outside of an office visit to determine whether a visit is needed! The world is moving in the direction of virtual, so we should too. Lastly, many wonder how we can possibly deliver care quality virtually? We can’t lay hands on the patients, can’t feel their pulse, auscultate their breathing, or visualize their optical nerve as we can in the clinic. As many senior physicians lament and younger physicians embrace but may be reluctant to say, the importance of the physical exam is waning as technology takes its place. There are devices that augment our abilities: the digital WWW.SFMMS.ORG

stethoscope that can algorithmically identify heart murmurs and the app that uses machine learning to assist us with diagnosing that rash. There have long been in-home testing kits for UTIs and yeast infections that can replace the dipsticks and KOH preps we do in the office. Connected peak flow meters, wireless blood pressure cuffs, even in home labs are now available to patients. Add in the Apple watch and you have single-lead ECGs at your disposal. Not only are we replicating our tools from the clinic, but new tools are being invented. At home DNA testing, sleep monitoring devices, step trackers, body fat calculators, and more are now available for use. Technology, smartly implemented and paired with caring physicians will be the path to better care. This data deluge from these sources is siloed, but once we have a tool to connect it all it will inevitably improve care beyond our wildest dreams. What are the ~2000 patients you have seen this year up to at this moment? Do you have a way to quickly look at their vitals in real time while they are sitting at home eating dinner? Can you identify those that gained an extra 10 pounds over the holidays? How about those who spent New Year’s Day in atrial fibrillation? With telemedicine you will soon be able to answer those questions, simply and easily. These answers will allow more efficient care delivery so that less time is spent on meaningless tasks, and will reduce the overall workload so that we are able to create the work-life balance that has escaped physicians in recent decades.


Our current world is one in which you see patients once, use crude and undependable physical exam maneuvers to make diagnoses and then may never get feedback on the patient’s outcome. The future world is one in which you see patients continuously, use highly accurate and precise tools to make diagnoses and monitor progress, and get to follow them over their lifetime, seeing their outcomes. Make no mistake, by providing truly connected care we will give patients more choice in their care, form stronger relationships with them, and ultimately create better outcomes.

James Wantuck, MD is Co-founder/Chief Medical Officer at PlushCare. He did a double major in Chem/Neuroscience at the University of Pittsburgh, and received his MD from Vanderbilt, doing a residency in Internal Medicine at Stanford. He is on the faculty at Stanford and VA Palo Alto. Passionate about using technology to improve patient's lives, he is currently building a virtual care platform from the ground up.




Can Tech Revolutionize Medicine?

Wearing Your Health on Your Sleeve:

THE PROMISES OF NEW WEARABLE MEDICAL TECHNOLOGY Kimberly Newell Green, MD A few months ago my 6-year-old daughter was found “down” on the school playground. When the teachers approached her she spoke with slurred speech and was initially unable to walk, having a very wobbly gait. Her unusual behavior lasted about 10 minutes and then she was reportedly back to her normal self. No one had witnessed what happened before this incident but there were no signs of significant trauma. Her pediatrician recommended an EEG among other things and so we spent an hour getting leads taped to her head with sticky glue to give us a one time, static look at her brain waves. The study was negative and was unable to fully rule out a seizure or other brain disorder, and gave us no answers to this scary and mysterious episode. Though frustrated, I was not surprised by this. As a general pediatrician, there is so much I cannot see or know. My patient Caleb has three ED visits and six asthma exacerbations in a year, and I can’t even easily tell if his parents have filled his prescriptions, much less whether they are using the medication appropriately or at all. I see Sofia every three months for her diagnosis of obesity with little to no insight into what happens between visits, and nothing changes. And Tarika comes to see me again and again for her nausea and abdominal pain that are symptoms of her anxiety but she cannot get a psych appointment that works with her school schedule or her parents’ work schedule, and can’t get an appointment at all for more than 3 months. The care we deliver today is limited in so many ways. Let’s say we see our patients four times a year, for 20 minutes each visit— depending on their age and health status, that’s very generous, as we all know. That means per year, we are not monitoring our patients’ health for more than 525,000 minutes. We can extend this to imagine the difference between our ability to statically monitor a vital sign or health parameter in the moment our patients are with us, compared to the massive volume of dynamic physiologic data that we are missing entirely. As a mother and as a doctor, I am blind, deaf and dumb to most of the factors that impact my patients’, and my own kids’, health. It is from this knowledge of our limitations that I look forward to the evolution of wearable technology and patientgenerated health data, which I think can and will radically transform the ways we care for our patients. It’s been about 10 years since the first wearable computing device, the Fitbit Tracker, was released in 2009. These early wearables arrived with great promise and excitement, and they sold like hotcakes! But wearables 1.0 had real downsides. Most people felt immediately engaged but didn’t stay engaged for very long. And people got frustrated with how often they needed to charge them. 22


The hype around first-generation wearables, as with many new technologies, eventually subsided. The innovation was taking a path known as the Gartner Hype cycle. Innovations often travel up a wave of excitement to the Peak of Inflated Expectations, only to fall into the Trough of Disillusionment. We physicians didn’t tend to get excited about introducing patient-generated data from wearables into our practices. Besides being afraid of interacting with the mounds of data they generated, physicians have had real questions about accuracy, and whether the parameters measured would actually contribute to better health outcomes. And what about the security and privacy Aand medico-legal issues of this patient data? Beyond these concerns, the healthcare community has had other worries about these devices. As with other digital health innovations, there are fears that these technologies will lead to the dissolution of the medical home—fears that technology might supersede or even replace the human connection that we, as doctors, know is a vital part of healing. In pediatrics we might wonder whether these tools provoke more panicked calls from the worried well, or an increased need for external validation of children's health and safety. But what if wearable devices could be transformed, and thus help transform the way we care for our patients? This is where the next generation of wearables, and other sensors and equipment remotely generating health information, is headed: Up the Slope of Enlightenment and toward the Plateau of Productivity. Here are some of the devices that are being envisioned, created, and honed this very moment. The familiar wearable devices like wristbands and watches (that monitor physical activity and sleep) are rapidly advancing, have extended WWW.SFMMS.ORG

capacity to measure more physiological parameters, and are being developed in new form factors. And many novel devices are being developed. There are devices that attach to phones that listen to lungs, or monitor heart rhythms. There are devices for infants, taking the form of socks or pacifiers or “smart” pajamas or teddy bears, designed to generate physiologic data like skin temperature, rollovers, breathing, or heart rates. There are devices designed to improve sleep quality that monitor, and send powerful sound waves into, our brains. There are devices that sense UV exposure and alert us when we’ve had too much. There are devices that monitor the menstrual cycle which as we know is an important “vital sign” for teenage girls. (It may be intriguing for some of us to also know that there is also a device that detects hot flashes and facilitates cooling). There is even a Tricorder X Prize, and companies are working to develop a Star Trek-like device that measures and tracks vitals and body chemistry. And then there are devices being developed to monitor movements of the elderly, and to send signals to help activate underused muscles to support ambulation and other activities of daily living. And so there is a massive rise in new tools and sensors, and they are getting better and better! The new devices are increasingly able to generate medically relevant, accurate, and reliable data. They are being studied at academic medical centers, their data is being validated against current standards, and the devices are gaining FDA approval. As with our electronic records, robust security protocols are being used to ensure privacy and safety. And no longer will we have to make sense of the firehose of data these devices are generating. Powerful tools like artificial intelligence and machine learning can generate actionable insights, can do the triage for us. Systems of flagging and notification can make sure that this information gets to the person that needs it, at the right time, and with the right level of urgency. What might all this look like in our clinics? I’ll share some of my dreams: • What if 8-year-old Caleb, the patient I mentioned before who has asthma, had an inhaler equipped to monitor his medication use and also send a series of escalating notifications for decrements in both external triggers like pollen count or air quality, and patient factors like wheezing, peak flow, and pulse ox? • What if we could help 13-year-old Sofia, who is overweight, monitor her eating habits and activity, understand the impact of her mood or environmental influences on her choices in the moment and over time, and then give her engaging methods to help her make healthy lifestyle choices? • What if we could monitor 16-year-old Tarika’s anxiety and stress levels, and give her tools to respond in a more healthy way just when she needs them? And there are many other examples, such as 10-year-old Kayla, with diabetes, who could continuously and noninvasively monitor her glucose levels through breathable patches on her skin or contact lenses, and passively send contextualized alerts to her family and the care system when needed, in a smartly tiered progression. WWW.SFMMS.ORG

With the technology of today and tomorrow, all of these scenarios are actually conceivable. Certainly there remain challenges and obstacles to changeuntil our health IT systems are fully interoperable, there are questions about where this data will live and how it will flow easily into our EMRs. As we all know, the payment models in our country are stagnant and evolve slowly, and so questions about who pays for these devices and the systems that support them remain.

With the technology of today and tomorrow, all of these scenarios are actually conceivable.

Despite these obstacles I believe that remote patient monitoring has truly transformational potential to improve health. And so I recommend we all consider a few questions deeply: When our patients and families are interested in using these new tools, and ask us to help them make decisions based on the information they are receiving, how will we respond? Can we imagine enlisting our patients to become our eyes and our ears, and in doing so, take off the blinders, and make our work more effective and efficient? And what are we going to do to help wearables 3.0 meet our needs? Could we participate in research to validate the accuracy of this data? Or get involved in co-designing the workflows and alert systems needed? And how might we advocate for payment model reform and advance important compatibility issues? As a mother, I crave this technology. I dream of an easy to don EEG that I can bring home to do continuous monitoring during my daughter’s rest, sleep, activity and stress to help elucidate the cause of the mysterious episode she had at school. As a doctor, I also crave this technology, because though I know we deliver great care today, we could do SO much more. So, Let’s get involved in designing the next generation of practice, because the change will be better if it happens with us, rather than to us. And then let’s get back to doing what we love most: caring for our patients and their families. Kimberly L. Newell Green MD is a pediatrician in San Francisco and Assistant Clinical Professor at University of California School of Medicine. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco where she practiced as a general pediatrician for over a decade and was a member of the senior leadership team. A graduate of Princeton University, she completed a Fulbright Fellowship in India and produced a documentary film about cross-cultural healthcare at the Harvard School of Public Health. She attended medical school at the University of Pennsylvania and completed her pediatric residency at UCSF, and completed the Kaiser Permanente Emerging Leaders fellowship program in 2015.



Can Tech Revolutionize Medicine?

How might we train pediatric residents as leaders to advance health equity?

APPLYING A DESIGN THINKING FRAMEWORK TO MEDICAL EDUCATION Jyothi Marbin MD; Contributor: Rita Nguyen MD In 2001, the Institute of Medicine called for a deliberate focus on physician leadership as a strategy to redesign the health care system and improve health care delivery.1 To serve as effective change agents and stewards of children's health, pediatricians must not only be able to provide outstanding clinical care to individual patients, but must also be able to develop innovations and apply systems-level thinking to transform the ways in which they partner with communities to advance health and health equity. Teaching design thinking during residency training is one strategy to help prepare residents to tackle these challenges. Design thinking reinforces critical competencies valued in the clinical setting, develops leadership skills in residents, and offers residents tools they can use in the pursuit of health equity. This article provides an overview of design thinking, and shares the experience of the Pediatric Leaders Advancing Health Equity (PLUS) residency program at UCSF in prototyping a design thinking curriculum as one promising approach in training pediatric residents as leaders and change agents in medicine.

What is Design Thinking?

Design thinking is a framework for creative problem solving that comes from product design, and has influenced most major companies looking to innovate and solve problems better.2 Design thinking has also taken root in the social impact space,3 including healthcare. Because design thinking places special emphasis on empathy and centers humans throughout the process, it produces solutions that work better for the user. In the health care/social innovation space, design thinking has been used to tackle problems such as reducing rates of pediatric sedation for MRIs,4 reducing malnutrition in children in Vietnam,5 creating low-cost neonatal incubators for developing nations,6 and increasing access to clean water in the Democratic Republic of Congo.7 Kaiser,8 Mayo Clinic, and Cleveland Clinic have all created “innovation centers” where design thinking is applied to envision and create the future state of health care delivery. Design thinking provides a systematic framework to collaboratively solve pressing problems, and places special importance on taking a human-centered approach to come to a more nuanced understanding of a problem. The five steps— empathize, define, ideate, prototype, and test9—are described briefly below: • The Empathize step allows designers to deeply understand the user experience through tools including interviews, observation and becoming users themselves. Design thinking



excels in encouraging practitioners to go deeper than quantitative data might reveal.

• The Define step allows designers to reframe the problem using insights gained from the human tensions, incongruities, and emotions gleaned from the previous step.

• The Ideate step encourages creative brainstorming to generate a variety of solutions to the new problem framing.

• In the Prototyping step, designers build a version of the solution and try it out on a small scale. In this step, failure is encouraged as each failure teaches learners something that can be integrated into the next prototype.

• The Test phase encourages rapid feedback cycles and continued iterative cycles. Design thinking is most useful in early stages of generating solutions, or when current solutions are not working.10 Whereas other methodologies used in medicine can be effective for incremental process improvement and improved efficiency, design thinking focuses on fostering out-of-the-box, creative solutions.11

Design Thinking and Residency Training: Leadership, Competencies and Addressing Health Equity

We chose to incorporate design thinking into the curriculum of the Pediatric Leaders Advancing Health Equity (PLUS) Program at UCSF for three key reasons: to develop leadership skills in our residents, to reinforce competencies valued in residency training, and to give residents a framework and tools for advancing health equity. First, equipping these budding physician leaders with a design thinking framework fosters the development of WWW.SFMMS.ORG

leadership skills that augment their ability to serve as innovators and change agents. Creative confidence, defined as the “ability to come up with new ideas and the courage to try them out”12 is an essential skill for those physicians who seek to answer the call to lead health care systems and reform13,14,15. The fast paced, iterative nature of design thinking helps residents develop creative confidence, empathy, and collaboration— all skills necessary for leaders dedicated to improving health care systems. Second, the design thinking skill set overlaps with more general characteristics we seek to develop in physicians. The design skill set includes the ability to analyze and synthesize information, turn ideas into solutions, demonstrate empathy to the needs of clients, take calculated risks, learn from failures, analyze problems from personal judgment rather than accepting existing solution, and develop comfort managing uncertainty.16 These are all skills we also value in physicians, and using design thinking offers residents a deliberate and structured way to apply these skills. Finally, design thinking offers concrete tools and strategies to tackle what Russell Ackoff and Robert Horn called “social messes”17. Most of the factors influencing health and wellness lie outside of the clinical context.18 Pediatricians caring for children are faced with the challenges of addressing the social messes— hunger, poverty, lack of access to health care, among others—that impact child health. These problems can seem insurmountable; design thinking offers us the tools of collaboration, problem redefinition and user centeredness to help us untangle some of these messes. By tapping into the experience and wisdom of patients and community members, design thinking helps us generate insights to redefine problems, identify new solutions, and help to deconstruct and better understand and address social messes affecting health.

Design Thinking and the PLUS Program

Given the alignment of design thinking with developing leadership skills and working towards health equity, we piloted a design thinking course in the PLUS Program in 2015. Twelve PLUS residents participated in a three hour “Design Challenge” facilitated by the Creative Skills for Innovation team at Google. The workshop was very positively received. One resident shared that the workshop was relevant “[on] a daily basis… [from] brainstorming differential diagnoses... to think[ing] about the hospital [experience] to working on bold, big new child advocacy projects.” Participants were unanimous in their desire to expand this training. Based on the success of this initial training, we were able to secure funding from the Academy of Medical Educators at UCSF to develop an ongoing Design Thinking for Health Equity workshop in partnership with leaders in design thinking from UCSF and Stanford. The workshop has been delivered to over 80 participants over two years, including medical students, residents, and public health employees. The training takes learners through each step of design thinking using a challenge that applies directly to them, such as wellness in work environments, or bike safety. Participants work through the challenge using a design workbook and with guidance from the facilitator. They WWW.SFMMS.ORG

are then encouraged to think about how they can apply the design thinking framework to their community based projects. The training has been extremely well received. Comfort with basic concepts including empathy, problem definition, ideation, prototyping, and getting feedback increased as measured by pre-post surveys. One month after the training, participants reported they were able to apply concepts including empathy, brainstorming and prototyping on community projects. Comments included: “I think I spend a lot of time thinking about how to implement an idea without actually trying it because of fear of failure. The comfort with failure in design thinking has stuck with me.” “During our community project, I was tasked with shooting and editing a video for our community partner. After storyboarding the project with the team, I moved quicker to actually shooting and editing the project than I normally would. I think this is because I was not afraid to make a bad edit. I showed several drafts to the team within the span of two weeks and they were able to give more substantive feedback because there was something already 'prototyped' or edited.” We continue to teach the “Design Thinking for Health Equity” workshop annually to residents and medical students at UCSF as they begin to work on community partnerships. As the interest in integrating design thinking into medical education grows, we hope to provide even more support for learners looking to use design thinking in health equity related projects in the future.

Future Directions:

The role of physicians is evolving beyond patient care to address systems level changes in healthcare. Design thinking is aligned with competencies we seek to develop in physicians, reinforces leadership skill development and offers collaborative tools as we work in partnership with communities to advance health equity. As we train physicians to lead change, and particularly as we seek to advance health equity in partnership with communities, integrating design thinking training into graduate medical education offers an exciting opportunity to develop a generation of physician leaders better equipped to meet the needs of patients, families and communities.

Jyothi Marbin, MD, is an Associate Clinical Professor in the Department of Pediatrics at UCSF. She is the director of the Pediatrics Leadership for the Underserved Residency program, the Director of Intern Selection for the Department of Pediatrics, and is an Associate Program Director of the Pediatrics Residency Program at UCSF. As an educator, Dr. Marbin is interested in developing curricula around building leadership skills to further social justice and health equity. Her areas of interest include diversity and inclusion, design thinking and adaptive leadership skills, including reflection and mindfulness. References on page 27




IN MEMORIUM Jeffrey Lynn Stevenson, MD Dec 16, 1953 - Dec 22, 2018 "I have lost a dear friend, almost a brother as I've known him for more than 20 years. He assisted me in all the cancer surgeries for his patients which is so typical of his commitment to them. I will truly miss his smile and determination." – Peter Bretan, MD, SFMMS member and CMA President-Elect Dr. Jeff Stevenson died in December. He was a longtime respected physician in Marin and leader in the Marin Medical Society and then SFMMS, where he served as a board member and delegate to the CMA. The obituary prepared by his family is below. He is already missed. It is with great sadness that the family of Jeffrey Lynn Stevenson announces his untimely passing on December 22, 2018. Jeff was born in Berkeley, California on December 16, 1953 to Merlon Lynn and Lois Griffin Stevenson, the third of five children. He lived life to the fullest and faced challenges methodically with courage and determination. He graduated from UC Berkeley in 1978 in Neurobiology and received his MD from George

Washington University in 1986. An army veteran, he served as a brigade surgeon reaching the rank of captain and was deployed in Korea, Belgium, Germany and Panama. After his service he worked in various Bay Area emergency departments, and provided occupational medicine services at several hospitals. He opened a private practice in Novato in 2005 and served as President of the Marin Medical Society in 2016. He was an avid cyclist and enjoyed working on old cars and motorcycles. He especially loved driving his 1966 Alfa. He is preceded in death by his mother and is survived by his father, his wife Charmaine, sons Vincent and Kirkum and siblings Leslie, Scott, Conrad and Cybèle.

David E. Willett, JD Longtime healthcare attorney and friend of the CMA and SFMMS David Willett passed away recently. He is remembered by many as a true expert and fierce advocate of the practice of medicine, and additionally, a nice and humorous man. A native Californian, born in San Francisco, graduate of San Mateo High School and the University of California’s Hastings College of Law, Dave joined the law firm of Hassard Bonnington in San Francisco, the 1970s, when they were the CMA’s legal counsel. Although the CMA eventually established its own inhouse legal department, Dave continued to provide scholarly legal advice and to draft position statements for the CMA on bills before the legislature and proposed state regulatory provisions. During his illustrious career, Dave also provided counsel to many physician practice groups, hospital medical staffs, component medical societies of the CMA, and numerous specialty societies in California. Recognized nationally for his expertise, perhaps one of his most unheralded roles was related to the adoption of medical malpractice tort reform in California. In 1975, CMA members proudly participated in what might have been an illegal work stoppage to bring to the public’s attention the intolerable increases in malpractice premiums for California’s physicians. A special session of the Legislature was called 26


by then Gov. Jerry Brown to resolve the malpractice crisis. After much haggling behind the scenes, the historic tort reform bill known as MICRA was signed into law. Dave Willett played a critical role in the development of that legislation, which then became a reasonable and fair approach to resolve medical malpractice claims, and those provisions have since become a model for tort reform in other states. He will be missed.



Richard J. Cohen, MD Friends and family are in mourning today, experiencing the December 25th death of Dr. Richard J. Cohen, an esteemed member of the medical community in San Francisco at age 82. A proud native of Brooklyn, New York, Dr. Cohen earned his A.B. degree at Columbia College in New York before entering Medical School at the State University of New York's Downstate Medical Center in Brooklyn. He interned at Walter Reed Hospital in Washington, D.C. before coming to San Francisco for a residency in Internal Medicine with subspecialty training in both Hematology and Medical Oncology at Letterman Hospital. He was sent to Vietnam in 1965, serving as Chief of Medicine at the 17th Field Hospital in Saigon, receiving a Bronze Star for bravery. After being invited to join a consultative and teaching medical practice in 1967, he continued to practice all three of his medical specialties until retirement in 2011. Especially renowned as a teacher to his peers and generations of residents and fellows in training, he delighted in giving the Sherlock Holmes lecture every December, teaching the art of deductive reasoning while dressed in a frock coat and deerstalker hat. In 2005, he was awarded the Charlotte Baer Award, the highest honor bestowed by UCSF to a member of the Clinical faculty. Emanating from his days in Brooklyn as a Dodger fan, he transferred his allegiance in baseball to the SF Giants, becoming a "Balldude" where he gleefully tore off his signature bow tie in the locker room to change into his full uniform which was emblazoned with Doctor C #18, which is "Chai" in Hebrew, or "Life." The love of his life was his wife of 59 years, Dr. Sandra Cohen, whom he met under incredibly romantic circumstances while a senior at Columbia and she was a student at Barnard. He was thrilled when she earned a Ph.D. degree from UC Berkeley and began her practice of Psychology. Survivors include his wife Sandra, their son Aaron of Berkeley, daughter and son-in-law, Eve and Keith Cohen-Porter of Denver, Colorado, his adored granddaughters, Thea and Bailey, and sister Hilary Mikoll (Gary) of Colorado. Contributions in Dr. Cohen's memory may be directed to Congregation Beth Shalom, 301 14th Avenue, San Francisco, where he served a term on the Board of Directors.


continued from page 25

1. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 2. Koklo, J. Design Thinking Comes of Age. Harvard Business Review Sept 2015. 3. 4. Kelley T and Kelley, D. Creative Confidence. Currency 2013. 5. view/1272/1089 6. Soule S. How Design Thinking Can Help Social Entrepreneurs. Stanford Graduate School of Business. October 2013. 7. 8. 9. 10. Roberts JP, Fisher TR, Trowbridge MJ, Bent C. A design thinking framework for healthcare management and innovation. Healthc (Amst). 2016 Mar;4(1):11-4. doi: 10.1016/j. hjdsi.2015.12.002. 11. Roberts JP 12. Kelley T et al. Reclaim your creative confidence. Harvard Business Review. Dec 2012. reclaim-your-creative-confidence 13. Ham C. Improving the performance of health services: the role of clinical leadership. Lancet. 2003;36:1978-1980. 14. Curry LA, Spatz E, Cherlin E, et al. What distinguishes topperforming hospitals in acute myocardial infarction mortality rates? Ann Intern Med. 2011; 154;384-390. 15. Wells R, Jinnett K, Alexander J, Lichtenstein R, Liu D, Zazzali JL. Team leadership and patient outcomes in US psychiatric treatment settings. Soc Sci Med. 2006;62:1840-1852. 16. Disposition of design: Koh, J. Design Thinking for Education. Springer Science & Business Media. Singapore 2015. 16. Horn, Robert E.; Weber, Robert P. (2007). New Tools For Resolving Wicked Problems: Mess Mapping and Resolution Mapping Processes (PDF). Strategy Kinetics L.L.C. 18. Tony Iton MD JD MPH,




Assemblymember David Chiu and Senator Scott Wiener present proclamations to Dr. John Maa on behalf of the California Legislature.

CELEBRATING 151 YEARS OF PHYSICIAN LEADERSHIP, ADVOCACY AND CAMARADERIE Nearly 150 physicians, community leaders, and their guests joined SFMMS for the 2019 Annual Gala on January 25, 2019 at Cavallo Point in Sausalito. Attendees were able to network with colleagues, meet SFMMS and community leaders, and take in stunning views of the Golden Gate Bridge from Fort Baker. Guests were treated to a lively reception with dancers and a fun and interactive photo booth. The festivities continued with a seated dinner and formal program that celebrated SFMMS’s history, its members, and their contributions to the local medical community. Immediate Past President Dr. John Maa was acknowledged for his contributions to the medical society, and 2019 SFMMS President Dr. Kimberly Newell Green received the President’s Gavel from Dr. Maa and delivered her inspirational remarks and vision for SFMMS. A special tribute to Dr. John Sikorski was provided for attaining 50-Year Membership status in the medical society, and Dr. Michael Scahill was honored as an outgoing member of the SFMMS Board. The evening’s program concluded with a very special memorial dedication to the late Dr. Jeffrey Stevenson with the presentation of a plaque to his son, Vincent. This was followed by the reading of the winning entry in the SFMMS physician-intraining writing contest. SFMMS would like to thank our members, sponsors, and special guests Assemblymember David Chiu, Senator Scott Weiner, Marin Board of Supervisors Damon Connolly and Katie Rice, and Alex Walker of Assemblymember Phil Ting’s staff for their support of the event and of SFMMS. Special thanks go to our event sponsors, including Presenting Sponsor, MIEC, and Platinum Sponsors, Brown & Toland Physicians and Kaiser Permanente. We hope to see you at the next SFMMS Annual Gala! 28


The 2019 SFMMS Gala was attended by 14 Past Presidents.

2019 SFMMS Officers from left: Michael Schrader, MD, Treasurer; Gordon Fung, MD, Editor, San Francisco Marin Medicine; Monique Schaulis, MD, Secretary; Brian Grady, MD, President-Elect; Kimberly Newell Green, MD, President; and John Maa, MD, Immediate Past President.



From left: Editor of San Francisco Marin Medicine, Gordon Fung, MD; SFMMS Executive Director/CEO, Mary Lou Licwinko, JD, MHSA; and SFMMS Immediate Past President, John Maa, MD.

SFMMS President Kimberly Newell Green, MD, presents Immediate Past President John Maa, MD, with a certificate of appreciation for his service. Dr. Maa then presented Dr. Newell Green with the President’s Gavel.

Dr. John Sikorski was born and raised in the factory districts of Detroit, Michigan. He graduated from the University of Michigan with a B.A. in Psychology, and then received his medical degree from the University of Michigan Medical School in 1962. He served as a psychiatrist in the U.S. Army Medical Corps, at Valley Forge Army Hospital at the beginning of the Vietnam War. He completed a psychiatric residency at the Sheppard & Enoch Pratt Hospital in Towson, Maryland, and a fellowship in Child & Adolescent Psychiatry at UCSF. He is board certified in both adult and child psychiatry. Dr. Sikorski is a part time UCSF faculty member serving as Clinical Professor in the Department of Psychiatry, in the Child & Adolescent Psychiatry Division, and the Psychiatry & the Law Program. In his private practice of 49 years, he has had extensive experience in family and juvenile court matters, and was a consultant for 10 years for the National Council of Juvenile & Family Court Judges at the University of Nevada in Reno. He also served for many years as co-chair of the Children’s Rights and Legal Issues Committee of the American Academy of Child & Adolescent Psychiatry. At the present time, Dr. Sikorski is interested in the impact of social media on adolescent development. He maintains an avid interest in opera, Italian cooking, saltwater fishing and sailing.

Marin Board of Supervisors, Damon Connolly and Katie Rice, acknowledged the significant contributions of Dr. Maa and partnership of SFMMS in addressing public health issues, including supporting a flavored tobacco ban in unincorporated Marin County.





2019 SFMMS President, Kimberly Newell Green, MD delivers her President’s remarks.

SFMMS President Kimberly Newell Green, MD presents a certificate of appreciation to outgoing SFMMS Board member, Michael Scahill, MD.

SFMMS recently lost Board member and Past President of the Marin Medical Society, Jeffrey Stevenson, MD. Dr. Newell Green presented a memorial plaque honoring Dr. Stevenson to his son, Vincent.

Andrea Rosati, PhD, MD, reads the winning entry of the SFMMS physician-in-training writing contest. The article was submitted anonymously by a resident.

Celebrating 151 Years Of Physician Leadership, Advocacy And Camaraderie
























UPCOMING EVENTS Physician Wellness Dinner Wednesday, February 27, 2019 at 6:00pm | San Francisco (venue TBD) Thursday, February 28, 2019 at 6:00pm | Marin (venue TBD) Physician leaders and medical group executives of Marin and San Francisco are invited to attend an executive briefing and discussion on one of the most important topics in healthcare today – Physician Wellness. The event is free and dinner is provided. For more information or to RSVP, contact Erin Henke at or (415) 561-0850 x268.

CMA Legislative Advocacy Day Wednesday, April 24, 2018 | Sacramento, CA

Join more than 400 physicians, medical students who will be coming to Sacramento to lobby their legislative leaders as champions for medicine and their patients during CMA’s 45th Annual Legislative Advocacy Day. Attendees will have the opportunity to meet with legislators on health care issues. Meetings with Marin and San Francisco legislators will be scheduled and coordinated by SFMMS. This is a unique event for California physicians and is free of charge to all members. For more information, please contact Erin Henke at or (415) 561-0850 x268, or visit

CLASSIFIED: For Rent: Fully equipped beautiful medical office in Mill Valley to share with one or two other physicians or medical professionals. Central location. Easy access. Lots of parking. Lab on site. Email: Phone: (415) 686-8310

Advertiser Index American College of Medical Toxicology . . . . . . . . . . . . . . . . . . . . . . . . Back Cover Cooperative of American Physicians. . . . 37 Doctor’s Company. . . . . . . . . . . . . . . . 33 Mechanics Bank. . . . . . . . . . . . . . . . . . . 8 MIEC. . . . . . . . . . . . . . Inside Front Cover Sutter Health CPMC. . . . . . . . . . . . . . . 21 Sutter Health NCH. . . . . . . . . . . . . . . . . 7


Maria Ansari, MD In medicine, as with many other aspects of modern life, technology is transforming the ways in which we access information and interact with others. At Kaiser Permanente, we’ve witnessed the introduction of new communications tools and technologies that are improving coordination of care among our medical personnel. These tools also empower patients by offering them greater access to information and new ways to receive care. One example is the replacement of pagers with a secure text-messaging program, Imprivata Cortext®, that complies with HIPAA standards of patient privacy. Unlike a page, the secure text message provides all the information needed to answer questions and make decisions on the spot. Cortext also allows doctors to message colleagues in other medical centers, improving coordination of specialty care. Another recent change is the advent of sophisticated apps with which patients can make appointments, fill prescriptions, obtain test results, and see their medical records all in one centralized location. The Kaiser Permanente app, My Doctor Online, also enables video visits using a secure HIPAA-compliant conferencing service. Surveys show that patients who have experienced a video visit welcome the service, valuing the ease and convenience. Advances in medical recordkeeping are also resulting in improved care. The popular EPIC system, used by Kaiser Permanente and many other hospitals and medical centers including Stanford and UCSF, allows record-sharing across offices and facilities. In the past, a patient who received medical care while traveling or from an outside specialist had to remember to inform her physician, but today that information transfers automatically into her chart. Of course, this is only the beginning; increasingly sophisticated technology is improving treatment outcomes in many fields, particularly oncology and cardiology. With our large number of patients and many specialized care facilities, Kaiser Permanente is positioned to take full advantage of technological breakthroughs and maintains a technology team charged with staying up to date on all new developments.

Tracy Zweig . . . . . . . . . . . . . . . . . . . . 11




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January/February 2019  

San Francisco Marin Medicine, Vol 92, No. 1, January/February 2019

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San Francisco Marin Medicine, Vol 92, No. 1, January/February 2019