Fall 2011

Stockton MRI

Up From The Ashes Fall Issue 2011 FALL 2011

SAN JOAQUIN PHYSICIAN

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Not oNly caN a disability slow your pace…

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NationalAssociation of Insurance Commissioners (NAIC). Article found at http://articles.moneycentral.msn.com/Insurance/InsuranceYourHealth/DisabilityInsuranceCanSaveYourLife.aspx.

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FALL 2011

Volume 59, Number 4 • September 2011

{FeATUReS}

22 36 44 63 FALL 2011

UP FROM The ASheS Stockton MRI Triumphs

ChRONIC DISeASe –

{DePARTMeNTS} 19

CALPAC UPDATe

26

DISASTeR ReCOVeRY FOR YOUR PRACTICe

28

IN The NeWS New Faces and Announcements

34

RISK MANAgeMeNT: Disruptive Behavior

53

hIPAA 5010 Standards Outlined

68

NeW MeMBeRS

59

eXPANDeD CARe MANAgeMeNT Health Plan of San Joaquin Update

Trending Up

A NeW COUNTY PLAN eMeRgeS

5 Year Strategic Plan for Public Health

DeCISION MeDICINe 2011

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Helping doctors treat and patients heal.

The Advanced Imaging Center

George M. Khoury, MD President

at Lodi Memorial Hospital offers Board certified radiologists, comprehensive diagnostic services, and a convenient location for patients.

Raissa Hill, DO President-Elect James Halderman, MD Past-President Thomas McKenzie, MD Secretary-Treasurer Board Members

High Field MRI Breast MRI Digital X-ray (walk-ins welcome)

Lawrence R. Frank, MD Ramin Manshadi, MD Karen Furst, MD

Moses Elam, MD Alan Kawaguchi, MD Kwabena Adubofour, MD

Peter Drummond, DO James J. Scillian, MD Kristin M. Bennett, MD

Medical Society Staff Michael Steenburgh Executive Director Debbie Pope Office Coordinator Gena Welch Membership Coordinator Committee Chairpersons

(209) 333-7422 Frank M. Hartwick, M.D. Majid Majidian, M.D. R. Brandon Rankin III, M.D. Grant W. Rogero, M.D. Roger P. Vincent, M.D.

MRAC F. Karl Gregorius, MD

Decision Medicine Kwabena Adubofour, MD

Ethics & Patient Relations to be appointed

Communications Moris Senegor, MD

Legislative Jasbir Gill, MD

Community Relations Joseph Serra, MD

Audit & Finance Marvin Primack, MD

Member Benefits Jasbir Gill, MD

Nominating Hosahalli Padmesh, MD

Membership to be appointed

Public Health Karen Furst, MD

Scholarship Loan Fund Eric Chapa, MD

NORCAP Council Thomas McKenzie, MD CMA House of Delegates Representatives Robin Wong, MD Patricia Hatton, MD

Lawrence R. Frank, MD James J. Scillian, MD Roland Hart, MD

James R. Halderman, MD Peter Oliver, MD

CMA House of Delegates Representatives - Alternates Kwabena Adubofour, MD

4

SAN JOAQUIN PHYSICIAN

Gabriel K. Tanson, MD

Ramin Manshadi, MD

FALL 2011

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MeSSAge > executive Director MeSSAge > executive Director

Inspiration comes “ Individually, we are in many forms one drop, but together we are an ocean.”

Often times it seems that my summer is consumed with our Decision Medicine program and the hundreds of hours our staff pours into it to make it the success it has grown into. This year was slightly different because I chose to relinquish much of the oversight to others and played a lesser role. For the most part I simply provided portage for the students by driving one of our rented vans each day.

I am known for saying that each year the group of 24 DM students seem smarter, more focused and determined. But without doubt, this was truer than ever before – we had an amazing collection of 16Th and year olds despite theirSusan youthKaweski, had already accomplished One Tracy new student ose17words werethat spoken

by Dr. San Diego County much.

Medical Society’s founded a website providing free services president during her recent installation ceremony. She further stated, “and united we must be, to Apple users several years ago that especially in these tumultuous times” to which I couldn’t agree more. These are difficult times now receives in excess of 2 million hits I am known for saying that each yearasthe for physicians and the medical community a whole. Far-reaching changes are happening a month, a sophomore girl from groupat of 24 DM students seem smarter, a break-neck pace in Washington, D.C., and at our own state capital. As Dr. Kaweski so Linden founded a non-profit foundation moreeloquently focusedstates, andwedetermined.

But withneed solidarity amongst our ranks like never before. One voice may belast year to benefit starving andtake another ignored this and no onetruer notices,than but when a chorus sings in harmony – it’s prettychildren hard to not out doubt, was ever before had orchestrated multiple fundraising – we notice. had an amazing collection of 16 concerts and events to help the homeless. and 17 year olds that despite their youth The common amongst them Membership is oft en perceived as a non-essential cost of doing business. thread Something you sign had already accomplished much. all was joined their giving and deep-felt up for out of habit or peer pressure. Some see it as a duty, having early spirit in their medical commitment giveofback those less career and never taken the opportunity to become more involved or seektoany our to services fortunate.

Andperception this groupisdoes not and so sadly, never truly see the value of membership because their own skewed consist of wealthy withofthe means contribute financially. halfthewill be the first towards it beingfamilies something little or notovalue.

Nothing could beMore furtherthan from truth. family member to college and familypersonal income benefi level falls nearopens the poverty level.of Despite Membership notattend only provides youtheir extensive ts, but a wide array these challenges, personally chose raiseasinaexcess $800 tothat, furnish the new Health pages Careers services to yourthey practice managers andtostaff whole.ofBeyond we could fill several Academy a full-size 25 stethoscopes.

Their gift moved the principal to tears with thewith extensive list ofskeleton servicesmodel CMAand provides as well. and made all of us in attendance very proud. To say these students were inspiring is the greatest of understatements.

To truly appreciate membership, you have to experience it or at least appreciate the extensive For an inspiring many of usininboth the medical community to go no lobbying takingstory placemuch every closer day ontoyour behalf Sacramento and D.C.you Forhave those further than who our cover article MRI and Dr. Javad I stillbilling, remember that horrific members have had to on callStockton us and request assistance withJamshidi. a collection, coding, image of their building on fire captured by allvalue of the newstomedia.

And more remember contract or personnel issue, membership is easy comprehend andvividly seldom enters visiting with “JJ”thoughts just daysaft after andhas walking the burned embers puddled water staff attempted their er help beenthru rendered.

For those thatand have attended our as annual House to recover what they could visit of computers, artifacts, and personal Hesecurely had justreinforced lost two multiof Delegates or yearly to the capital for Legislative Day,mementos. value is again million dollar greatest was inhas theinfact thatarenas they had saved his framed because theyMRI see fimagnets rst-handand the his impact our interest unified voice these of thought. medical diploma. The pain etched on his face was quickly replaced with fierce determination when I My ifhope you planning have had to therebuild. opportunity to seehe first-hand of your membership asked theyiswere “Of course said, mythe staffvalue is depending on me and Iand owe it to feel They’ve positive about contribution in do thethe future of medicine by being a part of them. stood the by me for all theseyou’re yearsmaking and I will same”. something bigger than Possibly even anbut ocean.

Few peoplemuch have inspired meyourself. more than Dr. Jamshidi, this summer I think I found 24 high school All the cut Best! students from the same cloth.

All the Best!

Mike Steenburgh Executive Director

Moris Senegor, MD Editor Editorial Committee Senegor, MorisMoris Senegor, MD MD Kwabena Adubofour, MD Editor Mike Steenburgh Editorial Committee Michael Shiraz Buhari,Steenburgh MD Kwabena Managing Adubofour,Editor MD Robin Wong, MD

Sherry Roberts

William West Creative Director Managing Editor sherrylavonedesign.com William@sjcms.org

Contributing Writers

MichaelCarmen Steenburgh Spradley Contributing Editor

Cheryl England Tom Gehring Sherry Roberts William West Creative Director/Graphic Designer sherry@sjcms.org

Contributing Sources

California Medical Association Contributing Sources California Los Medical Association Angeles County MedicalCounty Association Los Angeles Medical Association San Diego County Medical Society

San Diego County Medical Society

The San Joaquin Physician magazine

The San Joaquin Physician magazine is published quarterly by the is published quarterly by theSociety San Joaquin Medical San Joaquin Medical Society

Suggestions, story ideas or

Suggestions, story ideas or completed stories completed stories written by current written by current San Joaquin Medical San Joaquin Medical SocietySociety members members are welcome andbewill be reviewed are welcome and will reviewed by by the Editorial Committ the Editorial Committ ee. ee.

all inquiries PleasePlease directdirect all inquiries and submissions and submissions to: to: San San Joaquin Physician Magazine Joaquin Physician Magazine 30313031 W. March Lane, Lane, Suite 222W W. March Suite 222W Stockton, CA 95219 Stockton, CA 95219 Phone: 209-952-5299 Phone: 209-952-5299 Fax: 209-952-5298 Fax: 209-952-5298 EmailEmail Address: gena@sjcms.org Address: gena@sjcms.org Medical Society Office Hours: Medical Society Office Hours: Monday through Friday through 8:00Monday AM to 5:00 PM Friday

8:00 AM to 5:00 PM

Mike Steenburgh Executive Director

6 6SAN JOAQUIN SAN JOAQUINPHYSICIAN PHYSICIAN

FALL 2011 FALL 2010

FALL 2011

SAN JOAQUIN PHYSICIAN

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From The President < MeSSAge

Charting a New Strategic Plan: San Joaquin Medical Society Our mission statement: “SJMS is an organization of dedicated physicians who advocate quality healthcare for all patients and serve the professional needs of its members”.

This year we will be busy charting a new strategic plan that will expand on the previous plan plotted by Dr. Imeson and his Board over five years ago. We will continue to be all inclusive, have an open door policy to member physicians, with emphasis on increasing our membership base and expanding the Medical Society’s role in our community.

The Medical Society’s WEB site is www.sjcms.org and clearly exemplifies our mission with its many features and practice resources. Additionally, you will find several direct links to several of our endorsed partnerships which provide you, our member, substantial personal benefits.

Our quarterly magazine, San Joaquin Physician, routinely covers local stories and bios on our own membership and the wonderful work and contributions they have made. The strong support we receive

FALL 2011

by every local hospital, and many others in the form of advertising, is a testament of its impact in the medical community and the value it brings to all that read it.

We have a wonderful program “Decision Medicine” for young teenagers to encourage them in becoming future physicians and return to San Joaquin County and care for our population. We have had wonderful success stories along the way and we eagerly anticipate the fruit of our experiment in the very near future with our first DM alumnus medical school graduate.

Our Adult internship program is a very powerful means of educating our community and political leaders, teachers, and business owners of what we as physicians do and how we interact with our patients, the knowledge base needed to care for our patients, the technological advances in medicine and surgery and why medicine and health care are so costly. This has been an excellent pulpit for us to show how poorly our present health insurance

Medical Societies will have to find ways to maximize efficiencies and eliminate redundancy, share positive outcomes and methodologies, while maintaining individual autonomy.

ABOUT THE AUTHOR Dr. George M. Khoury is President of the San Joaquin Medical Society and practices at Stockton Diagnostic Imaging as a Radiologist.

SAN JOAQUIN PHYSICIAN

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Message > From The President

system manipulates health care for our population.

We are also working with local community based groups to establish ethnic centered chronic disease management programs and are looking for Physician Champions to step up and get involved. This is a coordinated plan with the Public Health department, our local hospitals, large medical groups such as Kaiser and Sutter Gould and our smaller groups and solo practitioners. We will be sharing more details about these new programs in the next few months, starting with this issue of the San Joaquin Physician’s article: “San Joaquin County Obesity and Chronic Disease Prevention Task force 5 year strategic plan” There are a number of challenges that many Medical societies in our state

are facing; some rapidly dissolving, others barely making it. Our medical society has been through its share of difficulties but with the guidance of our Board and our Executive Director over the past 5 years we have overcome such adversities and at present we are financially stable and are one of the few county societies that have seen positive membership growth over the past 4 years. The future economics of health care seems forebodingly depressing.

Medical Societies will have to find ways to maximize efficiencies and eliminate redundancy, share positive outcomes and methodologies, while maintaining individual autonomy. The California Medical Association (CMA) is also very concerned with these recent trends and is working diligently with local County Medical Societies to find ways to assist them in achieving, and

maintaining, financial security.

Finally, CMA has outlined both short term (completed by 2013) and long term (completed by 2020) Strategic plans. Our thrust will be to align our strategic plans with theirs so as to achieve a more cohesive, powerful, moving force and be a major part of the solution to the State and National Health Care Debate including Electronic Health care / Medical record and the Health Care Reform Act. The more active we physicians are at the local level with our patients, community leaders, state legislators and federal representatives the better chance we have to effect positive change. Please join with me and your additional elected leadership to engage in this mission and worthwhile effort.

California Medical Association Political Action Committee CALPAC needs your help to support candidates and legislators who understand and embrace medicine’s agenda.

Fighting for you!

Our top priorities are: 1. Protect MICRA 2. Preserve the ban on the corporate practice of medicine 3. Provide solutions to our physician shortage crisis!

Please visit www.calpac.org for more information

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FALL 2011

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Message > From The Editor

REFORM AND

THE EMBARCADERO FREEWAY Conceived as a freeway connection between the Bay Bridge and Golden Gate, the Embarcadero Freeway was partially completed in 1959, and ended on Broadway Street, allowing speedy access to North Beach and Chinatown.

ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.

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A recent article in the Wall Street Journal described a leader who is “scrambling to rescue his proposed overhaul of the state health system amid strong resistance from doctors, nurses and even members of the government that he heads.”

No, he is not Barack Obama. His name is David Cameron and he is currently the Prime Minister of the United Kingdom, who like his American counterpart came to power recently and brought along an ambitious reform agenda.

It turns out that just like us, the English National Health Service, derided on our side of the Atlantic as the worst example of socialized medicine, is also on the verge of insolvency. Among Cameron’s initial proposals which included further empowerment of doctors by having a say in budgetary decisions, was one that struck a nasty chord with his constituency: he proposed partial privatization

of the system to take some of the financial burden away from the government and transfer it to the private sector. It turns out that the big fear among the British is the creation of an “American style private system.” The article goes on, “doctors, nurses and opposition politicians have mounted an aggressive attack on the bill”, leaving Cameron on the defensive, with promises not to turn their beloved NHS into an American mess.

The British are our closest brethren in the world. We speak the same language, we have a partially common heritage, and we have allied with each other in numerous causes, including wars, for over a century. Historians point out the existence of a “special bond” between the U.K. and U.S, the sources of which are subject to much scholarly study. Having visited England many times, I commonly feel that the island is

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MeSSAge > From The editor

The only practical utility of this ugly edifice was fast access like a “51st state” of the U.S. It certainly seems less foreign to Chinatown for visitors in from East. If torn down, they to me than Alabama, Mississippi, or heaven forbid, South would have to spill into regular city streets with potential Carolina. Despite such close affinity with the U.S., our two consequences to Chinatown business. Thus, despite casting populations find themselves diametrically opposed in their a depressing shadow on the neighborhoods under it, the attitude towards health care. We are fearful of their heavily Freeway stood intact for decades. state controlled system replete with shortages, long waits, It took an act of God, the 1989 earthquake to initiate the and poor access to specialists, and they are afraid of our Wild demise of this Freeway, because it was not seismically sound.

West-like, dog-eat-dog private system.

At that point enough diverging political elements within the But are we, really, all that different? This article, small and City coalesced into consensus buried within the newspaper, to tear it down. But not before captured my attention those same Chinatown precisely because it made merchants exacted punishment me realize a surprising We all know what has happened from the leader that presided commonality between us. A since. Currently the Embarcadero over this decision. Mayor Art seemingly unrelated subject is a gorgeous palm tree lined Agnos, an otherwise popular can, I hope, help explain boulevard, lively and teeming and successful politician, saw how we are not, after all so his re-election effort go down divergent: it is the saga of the with residents and tourists alike, in flames, specifically because Embracadero Freeway in San featuring world class views, of the lack of support from the Francisco. restaurants, a re-enlivened Ferry Chinatown community who Those of you who have Building and more. felt betrayed by his activism been around since before in the Freeway’s successful 1989 surely remember this demolition. ugly overhead structure We all know what has that endowed one of the happened since. Currently the most scenic waterfronts in the Embarcadero is a gorgeous palm tree lined boulevard, lively world with a slum-like appearance. When I first visited San and teeming with residents and tourists alike, featuring world Francisco as a penniless college student back in 1977 I stayed class views, restaurants, a re-enlivened Ferry Building and in a YMCA youth hostel at the Embarcadero, which was more. It has assumed its rightful place along other world class located under its dreadful shadow. It was a seedy place, with seafronts. There is no question among us, the inheritors of dangers lurking in every corner. But at $4 a night it was all the decision that the Freeway needed to be torn down.

I could afford, and stay I did, miraculously emerging intact The saga of the Embarcadero Freeway is a good lesson from that neighborhood, and with a surprising new love for in resistance to change. Once a democratically governed San Francisco which eventually drew me near it. populace is accustomed to something, anything, tearing it Conceived as a freeway connection between the Bay down and starting anew takes a special energy, a political Bridge and Golden Gate, the Embarcadero Freeway was force strong enough to overcome inertia within the bodypartially completed in 1959, and ended on Broadway Street, politic. People would much rather live with an edifice, a allowing speedy access to North Beach and Chinatown. policy, or a way of life, no matter how many well perceived The remainder of the project never came to fruition because faults it may have, than to face a new unknown construct, of immediate revolt among San Francisco citizenry who and destruction of the familiar. Those who propose new recognized how it disfigured their beautiful city. “The freeway alternatives, “reformers” as they rapidly get to be known, revolt” as it came to be known, was successful in arresting do their best to express their vision to constituencies. More further construction. However, subsequent vocal critics who often than not, the populace views such proposals with wanted the double decker torn down did not have similar skepticism , fearful that the new might be worse than the luck. As it turned out, there was one strong constituency in existing. If one adds to this mix a powerful special interest the city who quickly adopted this new road as their life-blood, group,- in the case of the Embarcadero Freeway only one: and fought hard to preserve it: the merchants of Chinatown.

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MeSSAge > From The editor

the Chinatown merchants- , who are willing to spend time and money fighting against the “new”, inertia prevails by default.

When it comes to health care, both Britons and Americans are accustomed to systems that have served them since World War II. They are diametrically opposed, one socialist, the other capitalist, each with numerous flaws. Ironically, both systems appear outmoded for current times for the same reasons: medicine has become too sophisticated and expensive; human life expectancy has dramatically increased, resulting in higher demand for medical services; and most importantly, the cost of medical care has risen to levels that permanently threaten the economies of each country. Health care is a monstrous Embarcadero Freeway for

both the U.S. and the U.K. Furthermore, in both countries there are countless interest groups threatened by reform, not just one as in the more pristine San Francisco example. They are all willing to fight for their survival within their systems, faults and all. In any society individuals care for their own economic well-being first (if they can get away with it), before they worry about those of the others. It doesn’t matter how imperfect these systems might be, so long as they can continue feeding from their trough.

I had been perplexed by vociferous attacks against “Obama Care”, as it has come to be called, when it seemed like its vision, its details are still murky. No one quite knows precisely how some major elements of the restructuring, such as insurance exchanges,

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Accountable Care Organizations (ACO’s), or global payments will work out. This Wall Street Journal article about England made me realize that the details of the reform don’t matter. It is change itself that many oppose, some because, like the Chinatown merchants can see a clear threat to themselves, others because, faulty as it is, the current system is familiar, and there is more comfort in it than the unknown. I suspect the same psychology is at work in England with vocal opponents of Cameron’s reforms.

I am no longer penniless. I own a second home in San Francisco, and ride my bicycle regularly along the well marked bike path in the reborn Embarcadero, never tired of the gorgeous views it affords. The YMCA youth hostel is still there where it has always been, but with the Freeway torn down, it is no longer a foreboding place; in fact from the outside you could mistake it for a luxury hotel. I feel most fortunate to experience this magical City, one I consider the most beautiful in the world, with such ease, and nowhere is it more evident to me than in its Embarcadero. Wouldn’t it be wonderful if health care reform ended up with an equally satisfying result?

The Embarcadero is real, but paradise at the end of health care reform seems like a pipe dream to all, at both sides of the Atlantic. It certainly will take a lot of bloodletting to get there, more than just the political career of one mayor, and if we ever reach utopia, there will still be disgruntled interest groups who won’t recognize it as such.

FALL 2011

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fighting

for you!

Trial attorneys have already started a fight to overturn MICRA, there are ongoing efforts to erode the prohibition on the corporate practice of medicine, and there are continuous efforts to challenge your scope of practice.

As Chair of CALPAC (California Medical Association Political Action Committee), I wanted to give you an update on how CALPAC has been fighting for you in the political arena.

CALPAC supports candidates and elected officials that are friendly to the House of Medicine.

There have already been four special elections throughout the state this year: Assembly District 4 (North of Sacramento) CALPAC supported Beth Gaines, a republican businesswoman from Roseville. Mrs. Gaines handily won the election over democrat Dennis Campanale.

Senate District 17 (Antelope Valley) CALPAC supported former Assembly Member Sharon Runner, a republican businesswoman from Antelope Valley. Mrs. Runner also handily won the election over Darren Parker.

Senate District 28 (Los Angeles) - CALPAC supported former democratic Assembly Member Ted Lieu. Assembly Member Lieu defeated republican James Thompson and moved to the upper house.

Congressional District 36 (Los Angeles) CALPAC was instrumental in AMA’s Political Action Committee supporting democratic Los Angeles Council Member Janice Hahn.

SPRING 2011

Council Member Hahn defeated republican Craig Huey in the high profile race.

I can say that these members will now be strong advocates on our behalf.

Despite our successes, we still face many challenges. Trial attorneys have already started a fight to overturn MICRA, California’s landmark Medical Injury Compensation Reform Act, there are ongoing efforts to erode the prohibition on the corporate practice of medicine, and there are continuous efforts to challenge your scope of practice. Your support is needed to build on our successes and ensure that we have the necessary resources to prepare for the 2011–2012 election cycle.

These elections are going to be transformational for the California Legislative.

The Citizen’s Redistricting Commission has finalized Congressional, State Senate, State Assembly and Board of Equalization districts.

The perceptions of the commission’s decisions, good and bad, are likely to shape a national trend. These newly drawn districts, coupled with California’s open primary system, will result in a number of very contentious races.

CALPAC has extensively studied the new districts and is preparing for these high profile races on your behalf.

The bottom line is this: we must be stronger than ever to defend against increased challenges to physicians, both in the legislature and in the upcoming elections.

That is why I am asking for your support.

I have believed for some time that donating to CALPAC is one of the most important contributions that I make because it ensures Medicine has direct access to the policy makers that have the potential to come between me and my patients. Personally I have been a President’s Circle member for 9 years by donating $1,000 every year.

By making a contribution today, you will ensure we continue to have the most active political affairs operation in California. 2012 is going to be a very challenging year with many more high profile elections for us to be involved in than ever before.

Please visit www.calpac.org to donate today!

I look forward to working with all of you on behalf of our patients and our profession.

By Richard Thorp, MD Chair, CALPAC

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A LOCAL HEALTH PLAN FOR LOCAL PEOPLE...

Health Plan of San Joaquin is your community health plan – created by local people for local people.

That means decisions about our programs and services are made right here at home by people who know and understand San Joaquin’s community health needs.

It also means the personal doctors, pharmacists and area hospitals you trust can access our medical leadership to discuss your individual needs as a patient and assure you’re getting the best treatment for you.

Long time community physicians David Eibling, M.D. (Associate Medical Director) and Dale Bishop, M.D. (Medical Director) bring nearly 50 years of community health leadership in guiding Health Plan of San Joaquin.

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Call Health Plan of San Joaquin today to find out why a local health plan can make a difference for your family.

I

1-888-936-PLAN (7526) www.hpsj.com 1-888-936-

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We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

800-252-7706 www.CAPphysicians.com

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For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Francisco facial plastic surgeon Corey Maas, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

FALL 2011

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Stockton MRI Triumphs

Up From T 22

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By Carmen Spradley

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The Ashes FALL 2011

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New Office Rendering

Actual Photo

In the child’s game of rock/paper/ scissors, rock beats scissors, scissors beats paper, and paper beats rock.

Within that game is the essence, one could argue, of the universe-- the truth that life moves in a concentric play where power is a f luid commodity.

When the fire burst out and ate its way through the offices of Stockton MRI early one Sunday morning in March, a twist on this kind of interplay

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began. First match-up results: fire beats building.

But what happened next proved more compelling than the spectacle of 46 firefighters battling the two-alarm fire for nearly four hours. After the fire trucks left, Dr. Javad Jamshidi and the staff of Stockton MRI started a new battle--the struggle to keep the practice running. The next morning, Monday morning, without the benefit

of computers nor telephones, they managed to serve several patients.

Exams were given, and results were reported to referring physicians (via cell phones in “reading” mode).

Several hours after that, the team got electricity and equipment set up in a second office. By Thursday of that week, their server was back, and they were accessing patient records.

The next day, they had their digital office management and imaging systems back in place. Within a week, Dr. Jamshidi and his staff were back to nearly normal workf low. As of this writing, the practice is thriving, and there is talk of expansion. Battle number two: resurrection defeats destruction.

But why? Why did staff keep “going like mad,” as Stan Dobretz, technical and medical administrator, put it?

What compelled office manager Lisa Herbst to abandon her vacation and rush back to help? What drove the staff to come together, plan and execute a complexity of remedies as fast as they did?

In those first few moments after the f lames were gone, leaving only char and the smell of damp and smoke, Dr. Jamshidi himself wondered what would happen next. “I asked myself, what should come from the ashes?” Once staff came together and contingency planning began, the doctor shifted his perspective. “I was thinking of their side of the table.

They would be wondering, ‘What will happen to my job? How will I take care of my family?”

And there it is. If indeed life’s interplay is a concentric dynamic, one could find that elusive starting point within Dr. Jamshidi’s tendency to take in those around him, seek their perspective, and show respect for where they stand. This is an important part of the practice’s foundation.

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“I’ve been here from day one,” Lisa Herbst says. “Before the practice opened, we were painting walls, getting things ready before we could see our first patient. And Dr. Jamshidi always wants our feedback. He listens...our input is part of the mix. We feel like this is our place, too. So we take pride in it.”

The practice employs sixteen, all fulltime. Many are young mothers, who appreciate the flexibility they are given to rearrange schedules when necessary to take their children to appointments or to attend school functions. The practice holds Employee Appreciation lunches, celebrates birthdays, hosts an annual family picnic and Christmas dinner. Morale is high.

“Life has taught me a lot,” Dr. Jamshidi says. His take on the essence of the universe? “Love. Caring and love and paying attention to each other’s needs; we get so much back.”

The doctor lives by science and humanity. He speaks of molecules and Rumi. Success, to the doctor, is the by-product of the main goal, which is doing what you are doing to the best of your ability. He strives not for peaks, but for balance. These are the elements that make the person, who makes the doctor, who creates the practice, which resurrects itself. He speaks unabashedly of love and poetry, and in the next breath, advises his peers to read their insurance policies with great care. He provides proof that lofty ideals have very practical applications, and the article of proof is the quickness of the return to normalcy after the fire.

True, when it is your turn as paper, facing a looming pair of scissors, life can be daunting. But you can always rock, just like Dr. Jamshidi and the staff of Stockton MRI did. And you can’t beat that.

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Before and After You never know when, but you can know how.

Create and maintain a good team.

• Create and maintain a good work environment.

Listen to your employees. Show respect for their ideas, be flexible when necessary, and follow-through with commitments.

• Share responsibility.

• Take the time to consider matters through your employee’s perspective.

• Inspire by example.

Follow sound practices and safeguards.

• Establish safe handling for financial and patient records. Stockton MRI’s data, including dictation, which is done via voice recognition, is all electronic.

Patient billing was outsourced, so the billing company had copies.

• Keep a fireproof and waterproof safe. Back up disks and consistently take copies offsite.

• Equip server room with a fire protection system.

Stockton MRI’s servers are elevated on metallic racks, and have a sub-floor for the wiring.

• Have a back-up system installed on servers. Even though Stockton MRI experienced fire and water damage, and had no electrical connection, the UPS lights were still green. Techs were able to power up and retrieve the data directly from the damaged hard drives.

• Keep insurance coverage up-to-date and review it frequently.

Create a new normal right away.

• Advise scheduled patients of the situation.

• Reach employees.

• Contact service and support vendors.

• Communicate with insurance company.

• Restore electrical power as soon as possible.

• Establish a temporary space.

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How fast can your practice recover?

How to create a Basic Business disaster recovery plan in 4 Steps

Crown Enterprises offer Practices peace of mind by increasing the chances of quick technology and data recovery in the event of a malicious or natural catastrophe. We invite your practice to receive a FREE Network and Security Checkup.

Call them today at 209-390-4670.

L

oss of data is a common problem for businesses and medical practices alike. Fortunately, itâ&#x20AC;&#x2122;s a problem that can easily be avoided with the correct preparation. While devastating amounts of data can be lost during catastrophes like hurricanes, the September 11 terrorist attacks, fires and floods - it doesnâ&#x20AC;&#x2122;t take such large events to cause a business to lose important data. It can be as simple as dropping a laptop to the floor, or a power surge that results in burning out a storage device. If you donâ&#x20AC;&#x2122;t have your crucial data backed up, even a small situation can turn into a disaster.

If you still think natural disasters are the leading causes of data loss - and that the chances of it happening to you are pretty slim, take a look at the results from a study

by Strategic Research Corporation of the leading causes of business continuity and disaster recovery incidents: Hardware Failures (servers, switches, disk drives, etc) - 44%.

Human Error (mistakes in configurations, wrong commands issued, etc) 32% Software Errors (operating systems, driver incompatibility, etc)14% Viruses and Security Breach (unprotected systems are always at risk) 7% Natural Disasters 3% Establishing a disaster recovery plan can be done in the following four steps: 1) Take a potential risk inventory. Make a list of every potential cause of data loss

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and the solutions to each. Your list should include losses that won’t affect the business very much, and those that would shut the business down temporarily or permanently. Information Technology experts can assist you with creating the potential risk inventory - as they will have the knowledge and experience to identify possibilities that you are not likely to think of but need to plan for all the same.

These IT experts will also be able discuss preventative solutions to guard against each type of potential data loss.

2) Rate each of your potential data loss situations. How likely is it for each of the items on your risk inventory to occur?

Rating them in order of importance and likeliness to occur will help you determine where to focus your disaster recovery plan efforts.

3) Develop your disaster recovery plan.

Go through each of your potential risks and their solutions, and determine how long it would take you to recover from the loss of data for each risk. Could your business be offline for 24 hours?

A week? Depending on the nature of your business, being offline for even just 24 hours could result in your losing customers to your competition. Look at ways to reduce the length of time it would take you to recover from each type of data loss risk.

4) Put your disaster recovery plan to the test. Once you’ve created your plan of action for recovering lost data, you should test your solutions. A disaster recovery plan is just a plan until it can be tested and proven.

Crown Enterprises offer Practices peace

Procedures performed at our center currently include:

of mind by increasing the chances of quick technology and data recovery in the event of a malicious or natural catastrophe. We invite your practice to receive a FREE Network and Security Checkup. One of our Engineers will meet with you and/or your Office administrator to discuss your concerns and evaluate your network. You’ll know exactly where you stand from a technology perspective after this FREE service if you are a San Joaquin Medical Society member.

Call us today at 209-390-4670.

Article Contributor: Mark Williams, Owner and Senior Technical Engineer for Crown Enterprises, a firm specializing in practice management

• Colonoscopy • Bronchoscopy • Gastroscopy • Biopsy

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The Endoscopy Center of Lodi is a beautiful state of the art facility providing modern outpatient care. The Center is equipped with one fully state licensed operating room and a procedure room.

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(209) 371-8700 www.endoscopyoflodi.com

SAN JOAQUIN PHYSICIAN

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COMMUNITY > news

IN THE

NeWS

The California Medical Association Foundation (CMAF) has completed the 2nd edition of the Diabetes and Cardiovascular Disease Reference Guide (PRG).

Nearly half of all adults in the US have one chronic condition associated with an increased risk of cardiovascular disease.

According to the Centers for Disease Control and Prevention, 45% of individuals 20 years of age and older have high cholesterol, hypertension, or diabetes. In fact, the major complication of diabetes and the leading cause of death among patients with diabetes is cardiovascular disease. Adults with diabetes are also two to four times more likely to have heart disease or suffer a stroke than those without diabetes.

And, approximately 65% of patients with diabetes die from heart disease or stroke. Individuals with type 2 diabetes also experience high rates of blood pressure, lipid problems, and obesity, all contributing factors to cardiovascular disease.

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Providing staff, physicians and patients with relevant & up to date information San Joaquin County ranks 48th out of 58 counties for the percent of county residents 18 and older with diabetes, as reported by the California Diabetes Program (2009).

This translates to 9.2% of residents diagnosed with diabetes compared to 7% statewide.

• 42.3% of county residents with diabetes have been diagnosed with high cholesterol, compared to 37.8% of statewide residents with diabetes, and, • 65.2% have been diagnosed with high blood pressure, worse than the state average of 61.5%.

The impact of diabetes is especially visible among San Joaquin County’s Latino and African American populations.

Latinos in San Joaquin County account for 30.1% of the overall population and 9.3% of all diabetes diagnoses. African Americans account for 8.1% of the population yet the group disproportionately accounts for 15.9% of all diabetes diagnoses among all race/ethnic groups. Among those diagnosed with diabetes – • 63.6% of Whites, 62.1% of Latinos and 59.3% of African Americans were reported to have high blood pressure, and • 32.5% of Whites, 41.2% of Latinos and 48.7% of African Americans reported having high cholesterol.

Developing the Diabetes and Cardiovascular Disease Provider Reference Guide (PRG) The PRG was developed with the goal of bringing health care providers in a variety of practice settings current clinical guidelines, evidenced-based best practices and patient self-management resources to assess, manage and address diabetes as a cardiovascular disease complication. The PRG was coordinated by the CMA Foundation with the help of 29 physicians and health care professionals.

New additions to the 2nd edition: • Identification and management of prediabetes • An updated “Management” chapter that integrates blood glucose, hypertension and hyperlipidemia management all in one chapter (reflecting a more comprehensive management of diabetes) • Adult outpatient insulin guidelines for type 2 diabetes, including a decision matrix, from the Diabetes Coalition of California • Physical activity guidelines for type 2 diabetes • Tips to improve medication adherence • Updated pharmacotherapy grids to treat and manage

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news < COMMUNITY

diabetes, hypertension and dyslipidemia • A Diabetes Care Guidelines & Flow Sheet that allows you to easily identify all recommended care for your patient compared to target goals – all on a single page • Updated ICD-9-CM codes To access the new edition of the PRG please go to www.thecmafoundation. org/projects/aped Or to request a CDRom version at No Cost, please Contact Joe Mette, Diabetes Project Assistant at jmette@thecmafoundation.org St. Joseph’s Foundation Awards $18,000 in Scholarships

St. Joseph’s Foundation awarded scholarships to twenty-five students pursuing health care careers in nursing and nursing management, pharmacy, psychology, microbiology and clinical laboratory sciences, speech-language pathology, and medicine while attending San Joaquin Delta College, UC San Francisco, University of Phoenix, University of Nevada - Reno, Grand Canyon University, San Francisco State University, California State University at Stanislaus, Dominican University of California, and University of the Pacific. Candidate selection is based on academic performance and clinical excellence demonstrated in the patient care environment, as well as community service. The awards were made during an annual scholarship luncheon at St. Joseph’s Medical Center.

Monika Becker, Razia Dean, Jennifer Martins, Cassandra Vasquez, and Sue

White received Sr. Mary Gabriel, OP, Scholarships; Tanya Daniel and Minh LaTruong received Lillian Brughelli Scholarships; Adriana Ambriz received the Weaver – Haviland Family Scholarship; Laura Levitt and Jeffrey Zumstein received St. Joseph’s Auxiliary Scholarships; Barbara Hayford and Hieu Ha received Auxiliary Magnolia Branch Nursing Scholarships; Cammy Davis, Camay Harris, Hind Lalami, Nancy Lee, Andrea Semillo, Sarah Tait, and Candace Williams all received Luck-Lewis Scholarships; Tuan Ly and Lao Vang received Richards-Collier Family Nursing Scholarships; Bibiana Garcia, Deanna Peterson, Cosette Standridge, and Shannon Weber were awarded St. Joseph’s Foundation Scholarships.

“It is always rewarding to offer students support for continuing their education in some aspect of healthcare,” said Sister Abby Newton, O.P., Vice President of Mission Integration and Vice President of St. Joseph’s Foundation. “These students are our future nurses, physicians, and healthcare administrators. St. Joseph’s Foundation is honored to have the opportunity to help them succeed.”

In addition to Sister Abby Newton and St. Joseph’s Foundation Board President, Sherry Leonard, donors to the Scholarship Fund Theresa Weaver, MSN; Norma DePauli, Auxiliary Council Representative; Joan Sternecker, Auxiliary Branch Chair; Millie Lewis; and Pat Collier, RN presented scholarships.

Dameron CNO Graduates from the Johnson & Johnson Wharton Program for Nurse Executives

$18,000 in Scholarships

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Janine Hawkins, chief nursing officer at Dameron Hospital Association in Woodbridge, CA, recently graduated from the Johnson & Johnson - Wharton Fellows Program in Management for

Dameron CNO Graduates Nurse Executives, an intensive threeweek management education program held at The Wharton School of the University of Pennsylvania. Hawkins was one of 33 senior nurse executives selected to participate in the program, which provides participants with critical business and management skills that enables them to be effective leaders in the ever-changing health care industry.

This year’s participants are from Australia, Canada, Japan and the United States.

The Johnson & Johnson - Wharton Fellows Program has been enhancing the leadership capabilities of nurse executives for more than 25 years. The program recognizes the important and influential role nurse executives have in strategic planning within their own health care institutions and in shaping health care policy issues regionally, nationally, and globally. During the program’s Executive Forum, nurse executives collaborate with their health care institutions’ chief executive officers to analyze the role of nursing in hospital management and strategic planning.

“The Wharton program enabled us to better address the complex challenges nurse executives face,” Hawkins said.

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COMMUNITY > news

IN THE

NEWS

cars. We were told the population of Hanoi is close to 8 million, and there are 5 million motor scooters.

Because of limited living space, in the evening families eat dinner on the sidewalks in front of their homes.

The practice of medicine is very different than in the U.S. At our screening clinic in Haiphong, the room was filled with people. As we examined each patient the door, which was kept open because of the heat, was packed

abnormalities, adults who suffered the residuals of poliomyelitis (unusual in the United States), untreated trauma, and the residuals of undertreated infections. Access to medical care is at a premium, and when the word got out that the American specialists would be coming the demand to see us was “Effective nurse leadership ensures a significant. strong and sustained paint-centered The surgeons were bright, perspective is represented in strategic enthusiastic, and eager to learn. They planning and decision making.” seemed skilled and did an excellent job caring for the patients with what we Dr. Peter Salamon Visits would consider to be limited resources.

Vietnam to Provide Medical The hospital in Haiphong was unique Care and very different from anything we Over the last few years I have had the are used to in the United States. Rooms opportunity to are shared by work in a number many patients, of countries and much of around the the day-to-day world. My visit to care seemed Vietnam was truly to be provided unique. by their When I began families. It is my career in not uncommon medicine the after surgery United States was for the patient at war in Vietnam. to remain in I was on active the hospital duty in the United until the States Navy during postoperative that war. cast is removed Vietnam today (many weeks). is an active, vibrant At the Viet country. During Duc Teaching my visit I had Dr. Peter Salamon Visits Vietnam Hospital in the opportunity Hanoi I was to work in both surrounded by Hanoi and with other patients and families waiting eager young residents, many of whom Haiphong. These are cities which, prior to be seen, almost pushing their way spoke English, and all of whom were to my visit to Vietnam, were places that into the room. There were numerous interested, attentive, and eager to learn.

I remember from the nightly news 40 people looking in the windows of the Vietnam is a unique and beautiful years ago. Most of the people we met room. Privacy seemed to be of little country. Its growth has been and worked with were too young to concern. Needless to say, HIPAA rules astronomical. I eagerly look forward to remember the war that they refer to as were not apparent. returning to see more of the country the “American War.” The problems we saw were different and meet more of its people.

The cities we visited in Vietnam, St. Joseph’s Medical Group from those we see in the U.S. in our Hanoi and Haiphong, were bustling Receives Patient Satisfaction daily practices. There were many with people. There is traffic everywhere; Award children with untreated congenital mostly motor scooters, rather than

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news < COMMUNITY

St. Joseph’s Medical Group of Stockton, along with two other CHW Medical Foundation care centers, has been honored with the Avatar Exceeding Patient Expectations award. Those recognized include: • Mercy Imaging Centers, a service of CHW Medical Foundation in Sacramento • St. Joseph’s Medical Group of Stockton, a service of CHW Medical Foundation • Sequoia Medical Group, a service of CHW Medical Foundation in Belmont Avatar International Inc. is a leader in measuring customer expectations in healthcare. In comments about the honor, Dr. Michael Everett, Avatar Founder and CEO, says “Understanding the expectations of patients are what drive continuous improvement in healthcare. The basic definition of exemplary customer service is consistently meeting and exceeding your patient’s expectations.” This award is based on 2010 performance and is given to those organizations whose overall score has exceeded patient expectation scores.

“We are pleased to see that three of our outstanding care centers have been recognized for the excellent service they provide to their patients, says Jag Gill, ScD, FACHE, FACMPE, President and CEO of CHWMF. “Our employees and physicians work very hard not only to provide excellent medical care but also to ensure that our patients feel cared about and listened to, as if they are members of our own family.”

St. Joseph’s Medical Group of Stockton provides health care to its patients through a multi-specialty group providing primary care as well as

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specialty care in urology, general surgery and colorectal care. Backed by the heritage of St. Joseph’s Medical Center, the doctors are committed to providing easily accessible, personalized care to the community.

The awards were distributed at Avatar’s annual symposium in Orlando, FL at the end of June.

Vietnam Patients

Continuing Education Scholarships Provide Ongoing Support For Area Students

Health Plan of San Joaquin (HPSJ) recently awarded Health Careers Continuing Education Scholarships to eleven local students who are continuing their higher education with the goal of a career in healthcare. The recipients of the Health Careers Continuing Education Scholarships for the 2011-2012 academic school year are: Kimiko Agari University of the Pacific; James Cwick Montana State University; Diana Furukawa University of the Pacific; Valleri Gammon California State University, Stanislaus; Jordan Giudice Pepperdine University; Derek Leale University of California, Davis; Hansel Poerwanto University of the Pacific;

Danielle Rivera University of California, Berkeley; Vanessa Sanchez San Joaquin Delta College; Samuel Walker University of California, Irvine; Maria Yepez University of California, Santa Barbara This scholarship program endeavors to ensure the success of future healthcare delivery in San Joaquin County by supporting and encouraging high achieving students to continue to pursue their college education to achieve their goals of healthcare careers in San Joaquin County such as physicians, physician assistants, nurses, laboratory technicians and other general healthcare professions. These $1,000 “continuing education” scholarships were awarded to students who had initially received HPSJ’s Health Careers Scholarships as high school seniors and have demonstrated success in pursuing their college education.

David Eibling, MD, HPSJ’s assistant medical director, says, “The increasing demand for health services and a shortage of healthcare providers has resulted in a growing need for medical professionals in San Joaquin County.

Unfortunately, the rapidly rising cost of education can be a significant barrier for many of the individuals with the desire and academic capabilities to pursue the education needed for a career in healthcare. Health Plan of San Joaquin is firmly committed to advancing these future healthcare providers’ education with the support of the continuing education scholarships and wishes them all the very best as they pursue their degrees.”

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C E N T R A L VA L L E Y C O N F E R E N C E Saturday, September 24, 2011 7:30am – 11:30am Admission is FREE / Registration Required Stockton Golf & Country Club • Stockton, California Register at 209.952.5299 www.SJCMS.org

SPE AKE RS AND LEC T U RE T IT LES

David Tong, M.D.

Medical Director: Comprehensive Stroke Center

“Use of Telemedicine in Acute Stroke” Objectives 1. Understand the potential use of telemedicine for acute stroke management 2. Learn the current acute thrombolysis indications 3. Understand the pros and cons of using telemedicine for stroke treatment

Jeff E. Thomas, M.D., F.A.A.N.S., F.A.C.S.

Peter Weber, M.D.

“Vascular Neurosurgical Techniques”

“Epilepsy Surgery, Brain Tumors and Complex Spine Issues”

Objectives 1. Understanding the significance of a disease orientation, as opposed to technique orientation, toward cerebrovascular disease 2. Understanding the significance of a hybrid operating suite for that purpose 3. Understanding nuances of microangiography and digital-based interventions

Objectives 1. Understand the role for surgery and treatment of epilepsy 2. Understand the concepts of brain tumor syndromes of presentation 3. Understand the rationale for major spinal reconstruction in certain disease processes

Surgical Director: Interventional Neuroradiology Program

HOSTED BY:

Surgical Director: Epilepsy Program

Scott Rome, M.D. Medical Director: Physical Medicine & Rehabilitation Program

“Rehabilitation After Acquired Brain Injury: An Update” Objectives 1. Describe Hebb’s Neuroplasticity Postulate 2. Understand the Role of Neuromodulators & Plasticity after Brain Injury 3. Describe the Goal-Directed Behavioral Training Objectives after Brain Injury 4. Be familiar with CPMC’s Outcomes for Stroke Rehab Patients

SPONSORED BY:

Dameron Hospital Association (DHA) designates this seminar for a maximum of four (4) AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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RISK MANAGEMENT > Disruptive Behavior

M anaging

Professional Risk Behavior That Undermines a Culture of Safety

By Mary-Lynn Ryan, Risk Management NORCAL Mutual Insurance Company and the NORCAL Group

D

isruptive behavior by professionals in healthcare behavior, as well as the legal ramifications of limiting a settings is well documented as a threat to quality practitioner’s practice and the legal protections available to care and patient safety. Managing disruptive behavior both parties in such an action.1 requires a coordinated effort based on a written policy and One goal of a disruptive-behavior policy is to create a safe established procedures that cover reporting, confrontation, and supportive environment where everyone knows what is documentation, response, outside consultation, reprimand, reportable and feels empowered to make a report. Research follow-up, and monitoring, as well as support for subject indicates that many instances of disruptive behaviors are not physicians. reported because the Although there would-be reporter is is no universally afraid of reprisal.3 To Disruptive behavior compromises patient accepted definition of address this issue, the care and increases professional liability disruptive behavior, Joint Commission the American recommends risk. A lthough disciplining a healthcare Medical Association making the process provider for disruptive behavior can be (AMA) defines it as confidential and difficult for a variety of reasons , it must be “personal conduct, including nonwhether verbal or retaliation clauses done in a timely, organized and fair manner. physical, that affects in the policy. or that potentially Interviewing may affect patient reporters in care negatively.” It also includes “conduct that interferes confidence assures them that their reports are being taken with one’s ability to work with other members of the seriously.4 health care team.”1 Everyone who behaves inappropriately A history of delayed or hesitant responses to disruptive should be treated in the same manner, including excellent behavior can discourage staff from reporting such behavior practitioners.2 This expectation should be clear in the in the future. Therefore, it is important to investigate and policy. intervene as quickly as possible. Prompt response reassures All members of the healthcare team should be aware witnesses and reporters that the problem is being addressed of the policy and the definitions of disruptive behavior it pursuant to the policy. contains. Leaders who are expected to enforce the policy When the decision has been made to perform an should be trained in the process for addressing disruptive “intervention,” the designated team should plan every step

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(even rehearsing, if necessary), taking into consideration the effects and consequences of planned actions. The planning, goals and outcomes of an intervention should be carefully documented. If necessary, the resulting report can serve as evidence that the reported practitioner received due process.

An initial intervention without follow-up will generally not put an end to disruptive behavior, which tends to be triggered by ongoing circumstances in the healthcare environment (e.g., lack of equipment, understaffing, fatigue or practitioner health issues). A reported provider should understand that he or she is being monitored for compliance.3 Treat the reported behavior as a problem with the physician’s behavior, not with the physician.

In other words, the physician should not be labeled a “disruptive physician.”4 When it is too difficult to conduct an objective assessment in-house, an outside evaluation can assure the involved parties of the process’s fairness and objectivity. In some cases, the most prudent course will be to involve legal counsel for guidance.4 Disruptive behavior compromises patient care and increases professional liability risk. Although disciplining a healthcare provider for disruptive behavior can be difficult for a variety of reasons, it must be done in a timely, organized and fair manner. Individual practitioners who struggle with anger/frustration management must also take responsibility for their disruptive behavior and seek help. To create a culture of safety for patients and a supportive and productive environment for all members of the healthcare team, practitioners, Medical Executive Committee (MEC) members and administrators are encouraged to consider the risk management

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recommendations offered in this article.

It should be noted that in many states (including California) disciplinary actions based on physician conduct are reserved exclusively to the medical staff, not hospital administration.5 Endnotes 1AMA. Model Medical Staff Code of Conduct. Available on the AMA Web site at: www.ama-assn. org/ama1/pub/upload/mm/21/ medicalstaffcodeofconduct.pdf (accessed 1/21/2010).

2ECRI. Healthcare Risk Control.

Executive Summary. Medical Staff 8.

Supplement A. March 2009 Disruptive Practitioner Behavior.

3Weber, DO. Poll results: Doctors’ disruptive behavior disturbs physician leaders. The Physician Executive 2004: 30 (4) 6-14. (2004). Available on the ACPE Web site at http://net. acpe.org/resources/publications/ OnTargetDisruptivePhysician.pdf (accessed 1/18/2010).

4Joint Commission. Sentinel Event Alert. Issue 40, July 9, 2008. Behaviors that undermine a culture of safety.

Available on the Joint Commission Web site at: http://www.jointcommission. org/SentinelEvents/Sentineleventalert/ sea_40.htm (accessed 1/21/2010).

5California Medical Association (CMA). Disruptive Behavior Involving Members of the Medical Staff. CMA On-Call Document #1241. January 2009. Available on the CMA website at www.cmanet.org (accessed 1/21/2010).

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www.norcalmutual.com/cme.

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FALL 2011

CHRONIC

DISEASE

trending Up

As America ages, some chronic diseases are becoming more and more prevalent. Here are the most recent statistics for five common chronic diseases.

By David Reynolds Reprinted with permission from the Southern California Physician Magazine

America is aging. The first of the Baby Boom generation is entering retirement age—the first of a very large group about to transition to senior status. Americans are also living longer—long enough to develop chronic problems. And America is also getting heavier— eating more, and moving less. All of this adds up to an increase in many chronic diseases—osteoarthritis, diabetes, hypertension, and on and on. Many millions of Americans are affected by a chronic condition—and quite often, more than one related condition.

This increase in chronic disease burdens the health care system, and it is increasingly showing up in physician practices. Knowing the most effective treatment options and understanding how to encourage patient compliance is key to improving outcomes and keeping health care costs down. Here’s what research shows about five common chronic diseases: asthma, chronic obstructive pulmonary disease, diabetes, hypertension, and osteoarthritis.

FALL 2011

SAN JOAQUIN PHYSICIAN

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CHRONIC DISEASE > trending up

Asthma

According to the National Heart, Lung, and Blood Institute, one in 13 people in the United States has asthma. And while improperly controlled asthma imposes a cost on patients and families, it also affects the health care system. Acute asthma flare ups can claim primary care resources, disturb physician practice schedules, and increase emergency room and hospital bed use. Asthma control is within the reach of most individuals, which is good news since controlling the condition can reduce these burdens.

• In 2005, 8.9 percent of children in the U.S. had asthma.

• Each year, asthma causes 13 million missed school days and 10 million missed work days.

• Among children under 15, asthma is the third most common cause of hospital admission.

• The average inpatient stay for an asthma admission is 3.2 days.

• There were 42.3 asthma-related emergency room visits per 10,000 people in California. This rate decreases as patients get older.

Children under five have a rate of 101.3 visits per 10,000 people.

• In California, the number of emergency room visits for asthma is highest in the winter and lowest in the summer.

• African Americans have the highest rate of emergency room visits as a group—144.5 per 10,000 people in California.

• Nationwide, asthma-related emergency room visits top 200,000 and physician office visits top 10.5 million each year.

What to Look For

Since early diagnosis can provide some treatment benefits, consider extra followup with patients who: • have a family history of asthma; 40 percent of children with parents who have asthma will also develop the

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SAN JOAQUIN PHYSICIAN

condition.

• have allergies; 70 percent of those with asthma also have allergies.

• have airway hyperreactivity; • have atopy, such as eczema, allergic rhinitis, or allergic conjunctivitis; atopy has been shown to be a major risk factor for the development of asthma.

If You Can Only Get Your Patient to Do One Thing

Make an action plan. Work with your patient to create an asthma action plan. This written plan should include information on how patients can assess their own status, what medications to take under what circumstances, and when to call a physician. Self-monitoring techniques are especially important, so that worsening asthma can be recognized—especially for patients who may not be able to easily perceive symptoms, or for those who have had severe acute incidents.

Chronic Obstructive Pulmonar y Disease

The World Health Organization estimates that 210 million people have Chronic Obstructive Pulmonary Disease worldwide, and that five percent of all deaths globally in 2005 were related. And these deaths (primarily due to tobacco use or second-hand smoke) are projected to increase by 30 percent over the next 10 years. And while COPD is not curable, a solid, consistent treatment plan can control symptoms and provide patients with increased quality of life.

The Global initiative for chronic Obstructive Lung Disease, created in collaboration with the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the World Health Organization, provides COPD information, and is a worthwhile resource for physicians and patients alike.

• The COPD death rate for women is growing more quickly than for men. From 1980 to 200, the rate more than doubled (from 20.1 to 56.7 deaths per 100,000), while for men it increased more modestly (from 73.0 to 82.6 deaths per 100,000).

• COPD, when considered as a single cause of death ranks just under coronary heart disease, cerebrovascular disease, and acute respiratory invection, worldwide.

• By 2020, COPD is on track to be the third leading cause of death in the U.S. • In 2000, COPD-related emergency room visits topped 1.5 million.

What to Look For

Early diagnosis of COPD is key to preventing damage to lungs and providing the best patient outcomes.

Consider extra follow-up with patients who: • have a history of mucus blocking the airways; • have had shortness of breath; • have a chronic cough; • have exposure to risk factors, such as tobacco use or second-hand smoke.

If You Can Only Get Your Patient to Do One Thing

Manage the disease with medication.

COPD is managed through bronchiodilator medications, either as needed, or on a regular treatment schedule—tailored to the patient’s individual symptoms. While these treatments do not halt the reduction in lung function, they do help patients manage symptoms and can increase quality of life. As COPD progresses, patients often experience COPD flare-ups (usually in conjunction with a bronchial infection or irritation).

Managing these exacerbations can range from adjusting a patient’s medications to hospitalization, depending on the severity of the exacerbation.

Diabetes

Diagnosed cases of diabetes affects 17.9

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CHRONIC DISEASE > trending up

million people in the United States, with an additional estimated 5.7 million undiagnosed cases. Taken together, this is nearly eight percent of the country’s population. At least 57 million have prediabetes—indicated by a higher-thannormal blood glucose level (but under that needed for a diabetes diagnosis).

And, according to a 2008 report from the Centers for Disease Control, the diabetes rate has nearly doubled in the last ten years (with a strong tie to rising obesity rates).

This suggests that physicians will work with an increasingly large portion of patients who have the disease, and its myriad complications, including heart disease, hypertension, neuropathy, amputation, kidney disease, and blindness. Effective diabetes management will become more important—for physicians and their patients.

The National Diabetes Education Program is a coalition of the National Institutes of Health, the Centers for Disease Control and Prevention, and hundreds of public and private organizations, with the goal of reducing diabetes-related morbidity and mortality. NDEP has a wide range of publications and resources for physicians and patients.

• California has a higher incidence of

diabetes than the U.S. average, but a lower incidence of death.

• Marin, El Dorado, and San Francisco counties have the lowest incidence of diabetes in California; Yuba, Imperial, and Tulare counties have the highest incidence.

• $1 out of every $10 spent on health care in the U.S. is spent on diabetes (including complications).

• Diabetes is the sixth leading cause of death in the nation.

• Nearly 33 percent of people with diabetes also have severe gum disease.

• The risk of stroke for people with diabetes is two to four times more than for those without.

• More than 60 percent of people with diabetes also have hypertension.

• In 2007, diabetes cost the nation $116 billion in direct medical costs and $58 billion in indirect costs (such as missed work, disability, and premature mortality).

What to Look For

Identifying patients with undiagnosed diabetes as well as those with prediabetes can prevent or delay the onset of type 2 diabetes. Consider extra followup (including testing plasma glucose) with patients over 45 or overweight adults who: • have a family history of diabetes

Improving Patient Compliance With most chronic conditions, patient compliance is paramount.

Monitoring and controlling a chronic disease over the course of a lifetime is often challenging, and the best outcomes are tied to how well patients are able to adhere to a treatment plan. Here are some ways to increase patient compliance.

Build trust. Patients who trust and respect their physicians are more likely to follow that physician’s treatment plans. This includes building empathy and expressing concern and hope for patients, as well as including the patient in decisions, where appropriate.

Establish solid communication. This is a two-way street. Good communication ensures that patient concerns are heard and valued, and that physician instructions are heard and understood. Performing brief exit interviews is one way to ensure that patients understand. Tailoring the management plan to a patient’s situation and lifestyle help build communication and may increase compliance.

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SAN JOAQUIN PHYSICIAN

• have hypertension • is African American, Hispanic or Latino, American Indian, Alaska Native, Asian American, or Pacific Islander • had gestational diabetes • has vascular disease • shows signs of insulin resistance If You Can Only Get Your Patient to Do One Thing

Control blood glucose. Working with your patient to create a plan for managing blood glucose usually involves some combination of dietary control, exercise, and insulin (when appropriate).

By helping your patients become well educated about how healthy eating and physical activity, combined with monitoring blood glucose and using insulin as indicated, they can make informed decisions and effectively self-manage the disease on a day-today basis—and potentially avoid the complications of diabetes.

Hyper tension

Hypertension affects a large proportion of the country’s population—and most who have it don’t know it. According to the American Heart Association, one in three adults in the United States has hypertension, and over three-quarters of those who have it are unaware that

Five ways to get patients to cooperate

Ask a few open-ended questions. By giving your patients the opportunity to talk about what matters to them—whether or not it’s directly related to the issue at hand—you provide them with an opportunity to share, and that builds trust.

Increase contact. Scheduling more frequent appointments and making sure patients have contact with other resources can help improve compliance. Scheduling follow-up appointments before the patient leaves, as well as following up with patients who miss appointments can also help.

Understand cultural concerns. Patient compliance can be greatly affected by cultural concerns. By respecting and understanding these differences—as well as looking for ways that they can be incorporated into management plans—physicians can build trust with patients and families.

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SAN JOAQUIN PHYSICIAN 41

ChRONIC DISeASe > trending up

they do. And the death rate is rising— in the ten years ending in 2006, the hypertension death rate rose by over 19 percent, indicating that the disease is on the rise.

The National Heart, Lung, and Blood Institute (NHLBI) provides information to improve prevention and treatment of heart, lung, and blood diseases.

The NHLBI is part of the National Institutes of Health and offers a wide range of physician guidelines, research information, and patient education covering asthma, hypertension, obesity, and many other conditions.

• Over 74 million people nationwide have hypertension; over 60 million with hypertension in the nation are over 65.

• In 2006, hypertension was listed as a primary or contributing cause of death for 326,000 people in the U.S. • Hypertension will cost the country an estimated $76.6 billion in health care and lost work days.

• California has the highest number of lost work days per year due to hypertension in the nation.

• Over 140 different hypertension medications are available.

What to Look For

According to a National Ambulatory Medical Care Survey, hypertension is the most common primary diagnosis in the United States. Consider extra follow-up with patients who: • have a family history of hypertension; • are overweight; • are physically inactive; • use tobacco; • drink alcohol excessively; • exhibit high cholesterol, diabetes, kidney disease, or sleep apnea.

If You Can Only Get Your Patient to Do One Thing

Modify lifestyle. The first step in controlling high blood pressure is changing lifestyle. This includes weight loss for overweight patients, regular exercise, moderating alcohol

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SAN JOAQUIN PHYSICIAN

consumption, and adopting a calciumand potassium-rich diet with dietary sodium restriction, such as the Dietary Approaches to Stop Hypertension—or DASH—diet. Consider your patient and work to create a plan that addresses the most prevalent lifestyle issues.

Osteoar thritis

While the term arthritis covers over 100 diseases, the most common type is osteoarthritis. And although osteoarthritis can occur in any joint, it’s most common in weight-bearing joints, including the knee, hip and spine. Over 20 million Americans are affected by osteoarthritis, with most people over 60 having some degree of the disease.

It’s the most prevalent joint condition worldwide. As the population ages, the occurrence of osteoarthritis is projected to rise.

The U.S. Department of Health and Human Services, through the Agency for Healthcare Research and Quality, maintains physician guidelines and patient education resources for osteoarthritis.

• 27 million people in the U.S. have osteoarthritis.

• One of every two people will develop osteoarthritis in their lifetime.

• Each year, over 600,000 osteoarthritisrelated joint replacements are performed.

• In 2004, there were over 11 million osteoarthritis-related patient visits.

• Osteoarthritis accounts for over $128 billion in costs to the nation’s economy each year.

• 39 million physician visits and 500,000 hospitalizations annually are arthritis-related.

• By 2030, the number of people with arthritis is expected to increase 40 percent.

• Over 60 percent of arthritis patients are women.

If osteoarthritis can be diagnosed early enough, joint damage may be avoided through addressing underlying risk factors and providing preventative drug therapies. Consider follow-up with older patients who: • are female; • are overweight or obese; • have joint injuries or malformed joints or cartilage; • are employed in occupations that place repetitive stress on a particular joint.

If You Can Only Get Your Patient to Do One Thing

Address underlying factors. While pain relief is important for maintaining a patient’s quality of life (as well as the ability to follow an exercise plan), it doesn’t do anything to address the disease. If the disease is diagnosed early enough, addressing underlying factors may result in pain relief and restoration of function. Patient education may help in both of these realms. Chronic pain classes offered in many communities, and self-education resources on the Internet are two education options.

Regular contact with your patients may also help. One study reported in American Family Physician showed that monthly physician phone calls had good clinical outcomes.

Exercise and weight loss can both help patients with osteoarthritis. Patients who are worried that exercise will further damage a joint can be assured that low-impact exercise does not appear to advance the disease. Exercise can be used to maintain function, strength, and range of motion, and it also helps patients manage their weight. Obesity increases the chance of developing osteoarthritis and it adds additional stress on compromised joints.

What to Look For

FALL 2011

SJMS Is Proud to Announce an Exclusive Benefit for Its Membership – Prescriber’s Letter Online, Mobile Access, and 25+ hours of CME...

Dear SJMS member,

Search: (Help) Search: (Help)

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Your board members and I are always looking for ways to improve the value of your SJMS membership – constantly on the lookout for benefits that can help you practice your profession, or save your time, or your money.

Unbiased Evidence and Advice You Can Trust on New Developments in Drug Therapy

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We’ve had our eye on Prescriber’s Letter for some time now. We have often thought how great it would be to get this for SJMS members.

Email Us

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Manage My Account

About Us Mobile Tell Jeff Email Us Access Agreement

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And now I am so pleased it is a reality. Not only that, but we were able to get our members the highest level of service Prescriber’s Letter offers – its VIP Member level. VIP stands for “Very Informed Prescriber” and that speaks volumes about the special nature of this member benefit. Other physicians throughout the nation pay $250 for this service, and it is now included in your SJMS membership, at no additional fee to you.

CME

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• View/Change My Information Table of Contents of Current Issue • Change Email Notifications Search Issue Manage My Account Previous • Simple New Drugs• View/Change My Information • Browse • List of New •Drugs Change Email Notifications • Advanced Search

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• Patient Safety • Hematology / • Bone/Joint and • Pediatrics Oncology Rheumatology • Practice BasedRumor vs. Truth Infectious Diseases •Charts Cardiology Patient •Handouts Guidelines Issues • Men's Health • Dermatology Browse Comparison • Psychiatry • Natural Medicines Formulary/Drug • Diabetes andby Category • Neurology and Pain • Renal/Urology Endocrinology Safety • Hematology• /Respiratory•/ Patient •• Bone/Joint and • Nutrition/Obesity Allergy Drug Information • Pediatrics • Women's Health and • OTCs Oncology •Rheumatology Drug Interactions Ob/Gyn Gastroenterology • Practice Based • Infectious Diseases •• Cardiology • Ophthalmology

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You now get online access to each and every Prescriber’s Letter drug therapy recommendation as soon as they are posted. You also get all the evidencebased details behind each recommendation, and other practice tools such as the PL Drug Formulary Comparison tools, PL Patient Handouts in English and Spanish, Treatment Guidelines, and all the other PL Detail-Documents.

You can access all of this on your computer, or mobile device of your choosing, including iPhones and Android phones.

We were also able to reserve every SJMS member a space on the monthly webinars where the Prescriber’s Letter Editorial Board deliberates and decides upon the Recommendations to be published. Plus, if your schedule does not allow you to listen to these sessions when they are offered live, you will have access to listen to the archived recorded sessions whenever you want.

Through this new arrangement with Prescriber’s Letter, your SJMS membership now includes more than 25 CME credits per year at no fee to you. You can get these CME credits from reading the Recommendations – from getting your clinical questions answered online at the Prescriber’s Letter website – and by participating in the live webinars or listening to the recorded webinars.

To begin taking advantage of this members-only benefit, visit our website at www.SJCMS.org and click on the Prescriber’s Letter logo located on our homepage, or you can just call our office (209-952-5299) and we’ll handle the entire subscription process for you.

All the Best!

Mike Steenburgh Executive Director FALL 2011

Prescriber’s Letter Is Now a Member Benefit of the

SAN JOAQUIN PHYSICIAN

43

PUBLIC HEALTH > chronic disease plan

The Obesity and Chronic Disease Prevention (OBCDP) Task Force is pleased to present the San Joaquin County 5-Year Chronic Disease Prevention Strategic Plan. The taskforce believes that addressing these serious public health issues is a shared responsibility of not only the public health department and the health care community, but also of the private sector, community based organizations, schools, and advocates for healthier communities.

a new county

plan emerges!

By ShenĂŠ Bowie, DrPH, ACSM-HFS Program Coordinator, Health Promotion & Chronic Disease Prevention Public Information Officer, San Joaquin County Public Health Services

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SAN JOAQUIN PHYSICIAN

Community Response to Chronic Disease in San Joaquin County In October 2009, San Joaquin County Public Health Services convened local leaders, including some who had previously been members of the Steps to a Healthier San Joaquin Coalition. The new task force, composed of more than 40 individuals and partners, became the Obesity and Chronic Disease Prevention (OBCDP) Task Force which was designed to function as an umbrella coalition to promote community-wide collaboration through seven workgroups: Obesity and Diabetes, Asthma, Heart Disease and Stroke, Nutrition and/Physical Activity, Health Disparities, Policy Development & Advocacy, and Research/Evaluation.

The goal of the Taskforce is to develop a county-wide chronic disease prevention strategic plan to decrease the incidence and prevalence of obesity, chronic disease, and the related risk factors through a combined and expanded effort of the members.

FALL 2011

y es it ob

asthma

heart disease

FALL 2011

diabetes

SAN JOAQUIN PHYSICIAN

45

PUBLIC heALTh > chronic disease plan

THE 5­YEAR STR ATEGIC PLAN TO ADDRESS CHRONIC DISEASE IN SAN JOAQUIN COUNTY The strategic plan was developed by the task force in collaboration with representatives of several agencies, community based organizations, and professional associations. The plan is a result of several months of strategic planning that was conducted during spring 2011.

BACKGROUND ­ THE NEED FOR ACTION San Joaquin County is part of California’s Central Valley, one of the richest agricultural areas in the world, and is the fifth richest agricultural county in the United States.

According to U.S. Census estimates, San Joaquin County’s population in 2010 was 685,306, a 21.6% increase since 2000, approximately two times greater than the growth in California.

Furthermore, the county’s population is culturally diverse consisting of approximately 64% racial/ethnic minorities1.

The 2010 census estimates also indicate that the ethnic/racial composition of county residents included 51.0% White (with 35.9% being White and non-Latino), 14.4% Asian, 7.6% Black, 1.1% American Indian and Alaska Native, 0.5% Native Hawaiian and Other Pacific Islander, and 6.4% of persons reporting two or more races. Additionally, the 2010 census estimates showed 38.9% reported being of Hispanic or Latino origin. Slightly more than three-quarters of San Joaquin County adults are high school graduates, but only 17% of adults, compared to 30% statewide, have a bachelor’s degree or higher. In 2009, nearly 16% of County residents lived at or below the poverty level, compared to 14% statewide.

Stockton, the county seat, is the largest city with 43% of the population (290,141 2006 estimate) and two-thirds of all residents are racial/ethnic minorities2.

THE NEED FOR A COUNTY­WIDE CHRONIC DISEASE STR ATEGIC PLAN IS EVIDENT FROM THE FOLLOWING INFORMATION: The 2011 California Department of Public Health, Health Status Profiles showed that out of 58 counties, San Joaquin County had the 56th highest death rate for diabetes, the 55th highest coronary heart disease death rate, and the 49th highest stroke related death rate in the state. All of those chronic disease death rates were significantly higher 1 2011.

2

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SAN JOAQUIN PHYSICIAN

U.S. Census Bureau. State & County QuickFacts: San Joaquin County, CA, June U.S. Census Bureau. State & County QuickFacts: Stockton, CA, June 2011

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URINARY INCONTINENCE OVARIAN CYSTIC DISORDER LAPAROSCOPY Tonja Harris-Stansil, M.D HYSTEROSCOPY PRENATAL & POSTPARTUM CARE& TREATMENT OF CERVICAL, DIAGNOSIS Patricia A. Hatton, M.D HIGH RISK PREGNANCY UTERINE & OVARIAN CANCERS INFERTILITY, INVITRO FERTILIZATION Jennifer Phung, M.D. GYNECOLOGY ENDOMETRIOSIS Harjit Sud, M.D. OSTEOPOROSIS DETECTION CENTER URINARY INCONTINENCE We are proud to announce the opening of The Osteoporosis Detection Center using state of the art DEXA Vincent P. Pennisi, M.D. imaging.

DEXA scanning is now recognized to be the most accurate predictor of fracture risk in women.

OVARIAN CYSTIC DISORDER LAPAROSCOPY Stockton: 1617 N. California St., Ste. 2-A (209) 466-8546 • 435 E. Harding Way (209) 464-4796 2509 W. March Ln., Ste. 250 (209) 957-1000 • 10200 Trinity Parkway, Ste. 206 (209) 474-7800 HYSTEROSCOPY Lodi: 999 S. Fairmont Ave., Ste. 225 &230 – Ph. (209) 334-4924 ViLinda cki PatBouchard, terson-LamberM.D.t, R.N.P.C. DIAGNOSIS & TREATMENT OF CERVICAL, Manteca: 1234 E. North St., Ste. 102 – Ph. (209) 824-2202 UTERINE & OVARIAN CANCERS

ourewebsi l obgyn.com We are proud to announce the opening of The Osteoporosis Detevictsioint Cent r using tsteatate ofwww. the argt iDEXA imaging. DEXA scanning is now recognized to be the most accurate predictor of fracture risk in women.

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Denise

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Lynette Bird, R.N., B.S.N. Lynette Bird, R.N., B.S.N.

FALL 2011

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PUBLIC heALTh > chronic disease plan

than those in California as a whole3.

An important risk factor that tip of the iceberg. There are many In addition, in 2008, smoking cuts across many chronic diseases is factors associated with these issues prevalence, a risk factor for heart including dietary behaviors, local obesity and overweight. According disease and stroke, in the San Joaquin and school access to nutritious food, to the California Health Interview County region was 13.3% among opportunities for physical activity, Survey, 2007, 33% of San Joaquin adults compared to 11.6% statewide4. health services access, and workplace, County children in grades 5, 7, 9 and The May 2011 school, and community policies, San Joaquin County among others, that Asthma Profile promote adoption and showed that 15.5% maintenance of healthy of children have behaviors. asthma compared to This information 10.2% of children in reinforced the need California. Similarly, for non-traditional 9.3% of adults age partnerships and 18 and above have prompted the goal of asthma compared increased Taskforce to 7.7% California participation on the part adults. Furthermore, of private sector food it is estimated that outlets and retailers, as approximately 12,000 well as city and county Objective 1: By December 2016, adults in San Joaquin planners, commissioners, at least 15 residents or stakeholders County have asthma and elected officials caused by the workplace as this is critical to a will be trained to advocate for environment. Rates more comprehensive nutrition and physical activity of asthma emergency campaign. The Taskforce language in the general plan. department visits are is meant to pull together twice as high among the work and interest of San Joaquin County agency, organizational, children ages 0 to 4 (96.7 community, and resident per 10,000 residents) leaders to collectively compared to those ages address multi-level 5 to 17 (46.7). Adults age risk factors related to 18+ have an emergency chronic disease and department rate of 56.4% compared obesity. The Task Force has been 65% of adults are overweight or obese. to 36.4% statewide. Asthma related successful in securing several local Both proportions are higher than the hospitalization rates in San Joaquin grants to: address obesity and diabetes statewide prevalence rates for children County are 3 to 4 times higher among prevention and management, host and adults6. Recently released reports Blacks than whites, Latinos, or Asians. community discussions about also reveal that the highest economic Asthma risk factors include smoking, health disparities, hold a community cost of obesity in the California exposure to secondhand smoke, diabetes summit (February 2011), and central valley is in San Joaquin obesity, and living below the Federal plan an asthma community summit County and that soda consumption poverty level5. in spring 2012. in California is highest among the countyâ&#x20AC;&#x2122;s 12-17 year olds.

3 California Department of OBESITY PREVENTION The aggregated individual health Public Health: County Health Status Profile 2011 GOALS & OBJECTIVES status data indicated above is just the

y es it ob

4 Two Decades of the California Tobacco Control Program: California Tobacco Survey, 1990-2008 (2010).

California Department of Public Health California Tobacco Control Program.

5 California breathing:

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SAN JOAQUIN PHYSICIAN

initiatives and information for asthma advocates in California. San Joaquin County Asthma Profile, May 2011 6 California Health Interview Survey, 2007

Goal 1: Increase countywide leadership and coordination between nutrition and physical activity programs and collaborative.

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PUBLIC heALTh > chronic disease plan

Objective 1: By June 2012, the county will convene partners to collaborate on common goals and share resources and best practices that support healthy living and healthy environments.

Objective 2: By December 2012, the OCDP Task Force will launch a countywide campaign that promotes healthy food and drink choices and counter advertises for unhealthy choices.

Objective 1: By July 2012 there will be an additional 20 culturally sensitive selfmanagement classes for persons with diabetes and their families from qualified diabetes educators.

Objective 2: By December 2012, promote policies and practices with health care insurers and providers that will ensure effective obesity prevention and early treatment.

Goal 4: General plan will include

Goal #2: Collaborate/coordinate with providers, medical society, local schools, health plans, community leaders and community at large to increase awareness of diabetes standards of care.

Goal 2: Expand worksite wellness campaigns that promote healthy eating and active living.

diabetes

Objective 1: By December 2012, disseminate workplace policies that have been successfully implemented in California and across the nation.

Objective 2: By December 2013, increase by 20% the number of worksites that have created a worksite wellness plan specific to their agency, organization, or business.

Objective 3: By December 2016, 20% of the employers will implement the worksite wellness plan they created.

Goal #3: Improve access to healthy eating and physical activity in government, worksites, healthcare, families, schools, and industry.

Objective 1: By December 2012, the Obesity & Chronic Disease Prevention (OCDP) Task Force will launch a countywide media campaign that promotes public health and counter advertises sedentary inactivity.

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Objective 1: Develop standardized tool kits for providers, community leaders, and community at large by July 2012.

Objective 1: Create a directory of screening locations and of no cost or low-cost medical care options by March 2012.

Goal #3: Provide access to screening and referrals for available treatment options for those uninsured and under-insured with diabetes.

Objective 1: Create a directory of screening locations and of no cost or low-cost medical care options by March 2012.

policies that contribute to increased access to healthy foods and opportunities for physical activity.

Objective 1: By December 2016, at least 15 residents or stakeholders will be trained to advocate for nutrition and physical activity language in the general plan.

DIABETES PREVENTION GOALS & OBJECTIVES Goal #1: Offer culturally sensitive self-management classes for persons with diabetes and their families from qualified diabetes educators

HEART DISEASE & STROKE Goals & Objectives Goal #1: Increase education awareness of heart disease.

Objective 1: By December 31, 2015, increase the knowledge and awareness of San Joaquin County by 15% in regards to the dangers of high blood pressure.

Goal #2: Fully identify and strengthen all partnerships.

Objective 1: By December 31, 2011, fully identify all heart disease and stroke partners currently in San Joaquin County to enhance screening and avoid duplication.

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Goal #3: Enhance blood pressure screening efforts in the county.

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ASTHMA PREVENTION Goals & Objectives Goal 1: There will be a San Joaquin County Asthma Coalition.

Objective 1: By January 2012, the San Joaquin County Asthma Coalition will be established and include local partners.

Goal 2: Teachers and parents will have information necessary to determine when air quality is safe for children to be active outdoors.

Objective 1: By December 2011, the number of schools participating in the flag program will increase by 25%.

Objective 2: By May 2013, at least one training will be held for school staff and parents on Asthma Education, including triggers, irritants, cleaning products, etc.

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Goal 3: General plan will include policies that contribute to improved air quality.

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Objective 2: By 2016, increase the number of activities that promote air quality improvement by 12%.

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Physicians Advised to Begin Preparing for New HIPAA 5010 Standards Physician practices may need to make adjustments to the patient data they collect and report in order to comply with a new HIPAA requirement that takes effect January 1, 2012.

The new â&#x20AC;&#x153;HIPAA 5010 regulationsâ&#x20AC;? impact all health care providers who conduct administrative transactions electronically (including submitting claims, checking eligibility and claims status, or obtaining remittance advice and referral authorizations). The regulations cover all HIPAAcovered transactions, and therefore apply to most physician practices, health insurance companies and clearinghouses. The changes primarily impact software vendors and billing clearinghouses, but compliance may require medical practices to change some business processes as well.

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The medical society and CMA is advising members to familiarize themselves with these regulations and be proactive about making the needed changes to comply.

The Centers for Medicare & Medicaid Services (CMS) has advised that the regulations will not be delayed, and failure to comply will result in nonpayment of claims effective January 1, 2012. There are no exemptions for physicians who bill electronically based on specialty, practice size, or any other criteria. The remainder of this article provides background on the HIPAA 5010 regulations and guidance for physicians to plan ahead to minimize the risk of payment interruptions in 2012.

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PRACTICE MANAGEMENT > HIPAA 5010

Background: HIPAA 5010 standards Physician practices who conduct administrative transactions electronically (including submitting claims, checking eligibility and claims status, or obtaining remittance advice and referral authorizations) are required to meet Health Insurance Portability and Accountability Act (HIPAA) standards to perform such transactions. These standards ensure consistency in the type and format of data required in a given electronic transaction regardless of which billing vendors, clearinghouses or payers are involved.

Currently, electronic transactions utilize the 4010 version of the HIPAA electronic transaction standards. In 2006, CMS began the process of updating from the 4010 standards, which were originally developed in 2000 (and subsequently revised in 2002), to the “5010 standards”. The rationale for making the switch is that the 4010 version, just like any other software application, has become outdated.

Many technical issues have been found in transactions since 2000 and new business needs have been identified that cannot be accommodated with the 4010 version of the standards. For example, conversion to the 5010 standards is a prerequisite for the conversion from the current ICD-9 diagnostic code set to the new ICD-10 code set, which is mandated for October 1, 2013. The ICD-10 codes have a different format and length than the ICD-9 codes, which cannot be reported in the current 4010 version of the HIPAA transactions, so the upgrade to 5010 needs to be completed before ICD-10 codes can be reported.

Work was completed between 2006 and 2007 on a newer version of each transaction, Version 005010, commonly called “5010.” In 2009, the Department of Health and Human Services (HHS) and CMS announced that physicians and other health care providers would be required to use the updated 5010

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versions of the HIPAA transaction standards by January 1, 2012.

What is actually changing? Who does it apply to?

Physicians and other health care providers are HIPAA “covered entities”, which means they must comply with HIPAA requirements when conducting electronic transactions. Therefore, if you currently send and receive HIPAA-covered electronic transactions (including submitting claims, checking eligibility and claims status, or obtaining remittance advice and referral authorizations) and plan to continue doing so, then you will be required to upgrade to the 5010 standards.

The 5010 standards have reporting requirements that differ somewhat from the current standards. These changes may require you to collect additional data or report data in a different format.

Some (but not all) examples include: no longer reporting a PO Box in the Billing Provider Address field (PO Box addresses for payment purposes will now be reported in the Pay-to Address field); reporting a 9-digit ZIP code in the Billing Provider and Service Facility Location address fields; reporting a patient with a unique health plan member ID as the subscriber; and, only reporting minutes rather than units of anesthesia time.

You should consult your billing service, clearinghouse and payers to determine what changes will apply to your practice.

Is there any flexibility on the January 1, 2012, compliance deadline?

CMS has advised that these regulations will not be delayed. The necessary software and system changes need to be in place by the compliance date in order for you to continue sending and receiving HIPAA electronic transactions. Failure to comply will result in nonpayment of claims effective January 1, 2012. Any 4010 transactions sent on or after January

1, 2012 will be rejected as non-compliant and will not be processed.

You may begin using the 5010 standards in advance of January 1, 2012, to test the system and minimize the chances of billing interruptions. You can begin to use the 5010 transactions if you are ready and mutually agree to this with your clearinghouses or payers. Using the transactions before the deadline will give you the ability to see that transactions are working smoothly and are continuing to be processed. If any issues are identified, you can resolve them before the compliance deadline.

If you will not be ready by the compliance deadline, you will need to talk to your payers, clearinghouses, and billing service to determine what actions you can take to continue to have your transactions processed and receive payments.

What do physicians have to do to comply?

The biggest concern for physician practices will be complete implementation and full functionality of the 5010 transactions at or before the compliance deadline of January 1, 2012. Not all of the 5010 changes are IT changes and some will impact your business functions.

To avoid rejected claims and cash flow interruptions, physicians should work with their vendors, clearinghouses, billing services, and payers to upgrade and test their systems to ensure that they are able to successfully implement the new standards prior to the compliance date.

The American Medical Association (AMA) has developed several resources to assist physicians make the transition to 5010, including the following checklist: Talk to your current practice management system vendor. Be sure to ask the following questions: Will you be upgrading my current

FALL 2011

This is NOT Reaching

Meaningful Use! system to accommodate the 5010 transactions?

Can my current system accommodate both the data collection and transaction conduction for 5010?

Will there be a charge for the upgrade?

When will the upgrades be available?

When will the installation to my system be completed?

What resources to you have to help us covert to 5010 before January 1?

Talk to your clearinghouses or billing service, and health insurance payers. Ask the following questions: Will you be upgrading your systems to accommodate the 5010 transactions?

Will you be increasing your fees for the 5010 transactions?

When will your upgrades be completed?

When can I send test transactions to you to test that the system will work?

Will I need to re-negotiate my provider contract or electronic data interchange (EDI) agreement based on the move to the 5010 transactions?

What resources to you have to help us covert to 5010 before January 1?

Identify changes to data reporting requirements. Questions to consider are: Can we identify the data reporting changes for the various transactions we use?

Can we find resources to assist us in identifying the data reporting changes?

What is the cost of the resources we need?

Should we use a consultant to assist us in identifying the data reporting changes?

What is the cost of hiring a

consultant?

Which of this new data can be stored in our current system?

Which of this data relies on the system upgrade in order to store it?

Identify potential changes to billing and EMR systems, existing practice work flow and business processes.

Questions to consider are: Do we need to make any system upgrades? What is the cost?

Do we currently collect this data?

If not, how will we capture the data?

What added costs will result from new data collection methods, e.g. longer appointment times, revising existing forms?

What work flow processes do we need to change or add to capture the new data?

What are the costs of the newly revised work flow processes?

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Identify staff training needs.

Questions to ask include: Who should be trained on the transaction changes?

How long will it take to train the staff on the changes?

Will there be “downtime” during the training?

Should we use a consultant to conduct the training and if so, what is the cost of a consultant?

What resources do we need for the training and to support staff after training?

What is the cost of purchasing or creating the training resources?

When should training be completed?

Test with your trading partners, e.g. payers and clearinghouses.

Questions to consider about testing: What transactions should I test?

Which trading partners should I test with? Test the 5010 transactions with your payers through the Call us today for a complimentary consultation at

FALL 2011

(209) 390-467055 SAN JOAQUIN PHYSICIAN

PRACTICe MANAgeMeNT > hIPAA 5010

5 Action Steps Your Practice Can Take Now from the AMA

The following are five simple actions you can take now to start getting ready for the 5010 conversion. Please note: These are not all of the 5010 data reporting changes; you should check with your clearinghouses and billing vendors to determine the full scope of changes that apply to your practice.

Action 1: Is your practice reporting the appropriate Type 2 (organizational) National Provider Identifier (NPI) number for the Billing Provider on all electronic claim submissions? In 5010, you must bill all payers the same way using your lowest “level” Type 2 NPI for the Billing Provider. (For example, if your practice has an NPI at the practice level and you have a lab facility under the practice that received a separate NPI, then when billing for the lab services, you will be required to report the lab’s NPI. The lab’s NPI will need to be reported the same way to all of your payers.) If you are not doing this today, work with your payers now on making the changes to report your Billing Provider NPI correctly for 5010.

Action 2: Is your practice using the 9-digit ZIP code in the Billing Provider and Service Facility Location address fields in your electronic claim submissions? In 5010, the 9-digit ZIP code is required in these two address fields. Begin using the 9-digit ZIP code today in these locations in preparation for the 5010 requirements.

Action 3: Is your practice currently reporting a PO Box in the Billing Provider

address field of electronic claim submissions? PO Boxes are not permitted in the Billing Provider Address field in the 5010 claim transaction. The Billing Provider Address must be the street address or physical location of the Billing Provider. If you wish to have payments delivered to a PO Box or different address from the Billing Provider street address, report this address in the Pay-to Address field. If you will be changing the address you report today in the Billing Provider Address field, you should contact your payers about updating your enrollment information. Many payers use the address in their provider files to validate the physician, so they may pend or reject your claims if you begin submitting a different address in your claim.

You may also need to update your information in the National Plan & Provider Enumeration System (NPPES) (https://nppes.cms.hhs.gov/NPPES/Welcome.do).

Action 4: Is your practice currently submitting electronic claim submissions that accurately balance at the line level? This will be a requirement in 5010, so begin making the claim balance at the line level. Payers will also be required to ensure the electronic remittance advice accurately balances at the line level.

Action 5: Do you receive paper explanations of benefits? If not, now is the

time to consider moving to electronic remittance advices. Use of the electronic transaction is more efficient and cost-effective for physician practices. In preparation for the electronic remittance advice transaction, become acquainted with the HIPAA mandated Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that are used in the transactions. To access the current HIPAA CARC and RARCs, visit www.ama-assn.org/go/claims-assistant to access a complimentary look-up tool or visit www.wpc-edi.com and select “Code Lists.”

channels you use today to send and receive transactions. Specifically test with the payers and clearinghouses that make up your highest volume and/or highest dollar amount of claims.

When should I begin testing? Talk to your billing service, clearinghouses, and payers about the processes they will be using for testing. Follow their procedures and make certain that your testing is completed.

Will the testing be truly test data or will it use live production data?

Does everything work? Work with your vendor to fix any issues identified during testing and re-test with your billing service, clearinghouses, and payers.

Budget for implementation costs, including expenses for system changes, resource materials, consultants and training.

Do we have a backup plan? A major concern is the potential for disruptions in transactions processing after January 1, 2012. Physicians should develop a “backup plan” or safety net to address what they will do if their transactions do not work and they do not receive payments.

Where can I find more information?

A broad group of health care industry stakeholders (including the AMA) are coordinating their efforts to support a smooth and timely transition to the 5010 transactions and have developed free archived webinars that are available for viewing at GetReady5010.org.

These webinars will focus on testing the 5010 HIPAA electronic administrative transactions and feature speakers from the Centers for Medicare & Medicaid Services (CMS), and provider and payer organizations.

In addition, there are numerous online resources available from the AMA, the GetReady5010.org website, and CMS: American Medical Association website on “Version 5010 Electronic

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Administrative Transactions” (http://www.ama-assn.org/ama/ pub/physician-resources/solutions-managing-your-practice/ coding-billing-insurance/hipaahealth-insurance-portabilityaccountability-act/transaction-code-set-standards/version5010-electronic.page ). The AMA’s website includes: 5010 FAQs AMA’s archived webinar, “5010 and ICD-10: What They Are and How to Prepare for Them” “5010 Checklist” that lists activities to guide physicians through their implementation of the Version 5010 HIPAA transactions “5010 Project Plan Template – Helping Practices Prepare for the New HIPAA Standards” “7 Steps Practices Can Take Now to Prepare for 5010” 5010 Fact Sheet Series Links to additional resources

materials on testing of 5010 transactions If you have questions or need assistance obtaining additional information, please call the CMA Helpline at (888) 401-5911.

Prognostication is not a science, …comfort care is.

Centers for Medicare & Medicaid Services (CMS) website (http://www.cms.gov/ Versions5010andD0/ ). The CMS website includes: Preparing for the Electronic Data Interchange (EDI) Standards: The Transition to Version 5010 and D.0 New Health Care Electronic Transactions Standards Versions 5010, D.0, and 3.0 Transition to Versions 5010 and D.0: Checklist for Level I Testing Activities Transition to Versions 5010 and D.0: Provider Action Checklist for a Smooth Transition GetReady5010 website (http:// getready5010.org).

An education effort supported by the AMA and other health care industry stakeholders to support a smooth and timely transition to the 5010 transactions Includes physician resources, as well as free webinars and

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Expanded Care Management at Health Plan of San Joaquin

Care Management is defined as “a collaborative process between patient, physicians, and a care team which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality and cost effective outcomes.” Importantly, this aligns with Health Plan of San Joaquin’s (HPSJ) mission statement.

HPSJ has expanded and revised the roles of its Medical Management team to continue to provide the highest quality care in the most efficient manner, while preparing for new membership and opportunities to expand the Health Plan’s reach. The Department of Health Care Services (DHCS) has begun moving a new group of Medi-Cal patients -- Seniors and Persons with Disabilities (SPDs) -- into the Medi-Cal Managed Care program. >>

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CANCER SYMPOSIUM for Clinicians and Medical Staff

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This statewide effort seeks to improve coordination of medical care within the Medi-Cal population. To meet this new population’s needs, HPSJ’s Care Management team expanded to address the complex needs of all our members.

HPSJ has developed a process to review the new members and identify those with greatest health and social needs. Upon enrollment in HPSJ, all SPDs are stratified into risk groups.

This process uses prior health information regarding diagnoses, medications, recent hospitalizations and ER visits provided through state data of the member’s recent history in the fee for service Medi-Cal program. Members are contacted by phone to complete a Health Risk Assessment to determine if assistance is needed on key points in their care, and then referred to a member of HPSJ’s Care Management team based on the assessment. A customized care plan is forwarded to the Primary Care Physician to assist in establishing the care assessment and team approach to our members care. Results of this process are reported to DHCS to track and monitor outcomes of this new program.

HPSJ’s team has been expanded into a Comprehensive Care Management Team with RNs, medical assistants, care navigators, LVNs, social workers, pharmacy technicians, Pharmacist’s, health educators and primary care and specialty physicians. All team members collaborate toward a comprehensive, coordinated assessment regarding appropriate care needs of HPSJ members.

Training has been a vital part of the new approaches being developed at HPSJ. In June, nursing staff attended a learning session for Care Management Plus - a care program focused on the older population and the health needs related to this group developed by Oregon Health & Science University. Online continuing education provides the nurses with opportunities for ongoing learning about additional topics. Among the issues addressed: diabetes, dizziness and falls, asthma and COPD, hypertension and heart disease, depression, sleep disturbances, pain, hospice and palliative care, advanced directives, management of frail elders and motivational interviewing in healthcare. A goal of this program is for nurses to reach out to medical providers within the HPSJ network to assist with the care of members with unique needs, as well as to provide member education to support their involvement and ownership of

their care and disease management.

In addition to the development of the Care Management Team, the expanded use of the Medical Home Model has started. This concept promotes the primary care physician as leader of a team that takes collective responsibility for patient care. The team is responsible for coordination of the health care needs of assigned members. HPSJ is supporting our coordinated care for our members through the development of Medical Homes with a number of efforts, including:

Electronic Health Records (EHR) - Assisting primary care practices in evaluating and transitioning to EHR’s.

Disease Registry- HPSJ ’s HEDIS Projector which is a service in HPSJ’s computer system that provides physicians with lists of members in their care in need of preventive care or disease management attention.

24-hour Advice Nurse Phone line - Members can speak with an RN for medical advice, or before seeking urgent or ER care, as a complement to the physician’s after- hours call system.

HPSJ Care Management Team - Nurses and social workers are able to visit the physician’s office to assist with education and communication with our members and their unique care needs.

Home Visits - A Family Nurse Practitioner supports efforts toward early intervention and treatment by going to the homes of members with significant medical problems. In- home assessments may reduce emergency room visits and possible hospitalizations, as well as identify unsafe living situations.

The Care Management Team is excited by the new efforts and opportunities to partner with our network of physicians to improve health outcomes for our expanding membership. If you are interested in hearing more about these programs and services, and how to integrate them with your practice, please call Brenda Hill RN, COHN-s 209-461-2269.

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Decision Medicine 2011

A Reflection of our Society

By Daniel Rios, Lead Program Facilitator

S

an Joaquin County has been blessed with the best. We have diverse food, wine, entertainment and a robust population that continues to grow.

From immigrant to Native, English speaking to foreign dialects and privileged to underrepresented, San Joaquin County has a wide array of people within its unique region that few can match. We now have a new item to add to this list of bests: future doctors.

Despite this great mix of people from different backgrounds and ethnicities, the demographics of physicians in our area remain lop-sided. With this issue being identified, the San Joaquin Medical Society created the Decision Medicine Program in 2001 with the financial backing of Kaiser Permanente and Health Plan of San Joaquin. Decision Medicine sought to find a variety of high school students from all over San Joaquin County who are aspiring to become physicians and plan to come back to serve the area that they are from.

One day soon, these diverse group of kids will be a diverse group of doctors working in what will soon be San Joaquin Countyâ&#x20AC;&#x2122;s diverse medical field.

Each Decision Medicine student went through an extensive application process. The students applied online, answered multiple questions in essay form and finally, had an interview from a panel of board members of the San Joaquin Medical Society, including several doctors. During the application process this year there were more than one hundred students who applied.

The field was then narrowed down and just twenty-four stellar students were chosen to participate in the program.

These young adults are some of the top students at their respective high schools. The mean GPA for this group was an outstanding 4.6 and three of these students compiled a perfect 5.0 weighted grade point average. The high

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achieving and academically driven students are from various towns in the county including: Stockton, Lodi, Tracy, Mountain House, and Linden.

A recent study on the enrollment of medical students in the United States found that women are quickly filling the majority of spots on a school’s roster. Hospitals and private practices used to be largely male dominated but that era is soon coming to an end. As Dr. Moses Elam, Physician-in-Chief of Kaiser Permanente of the Central Valley told the Decision Medicine students in July, “Watch out boys, the girls in this group will be your biggest competition!”

The trend was ref lected in this year’s Decision Medicine program as nearly two-thirds of the students were young women. This increase is much welcomed as it will provide gender equity to the field.

However, there is still a lack in ethnic and language variance among doctors in San Joaquin County.

In order to combat this problem, Decision Medicine attempts to cater their program towards underrepresented and ethnic minority students. This year, nearly one-half of the students f luently spoke another language other than English. These languages include: Punjabi, Guajarati, Hindi, Kapangpangan, Mandarin, Cantonese, Korean, Vietnamese, Hmong and Spanish.

The idea is that if these students are made aware of the dire need for diverse physicians and provided with the resources to succeed; they will bring their talents back to our area and serve in the communities in which they are most needed.

Each day of the program the students participated in a multitude of activities. They were able to take exclusive tours of local facilities such as St. Joseph’s Medical Center, Dameron Hospital, San Joaquin General Hospital and various Community Medical Centers. The students were also able to see some facilities outside of San Joaquin County as they visited UC Davis Medical School in Sacramento and California Pacific Medical Centers in San Francisco. In addition, the participants had the opportunity to draw and type their own blood, become CPR and First Aid certified, and even dissect a pig’s heart. Towards the end of the two week program each student was provided with the opportunity to individually shadow a local physician. The students were paired up with a

This year, nearly one-half of the students fluently spoke another language other than English. These languages included: Punjabi, Guajarati, Hindi, Kapangpangan, Mandarin, Cantonese, Korean, Vietnamese, Hmong and Spanish.

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At A Glance

This year’s group of students represented 15 different high schools and 7 various cities within San Joaquin County.

Selected from a pool of nearly 100 applicants, the average GPA of the final 24 exceeded 4.5 Christopher Low, Anmol Bhangu and Connor Phillips take in a lecture at UC Davis Med School.

Observing Dr. Rick Rawson for a morning of surgeries was the highlight of the program for students Morgan West and Alexis Sandoval.

physician that closely matched their area of interest and then observed the doctor for half of the day. The students were able to see the inner workings of various medical settings and a few of the students were able to experience a live surgery. With these opportunities, the already ambitious and driven students are one step closer to achieving their goals and bringing a much needed

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change to the face of medicine in our region.

San Joaquin County is filled with people from all walks of life and its medical field should ref lect its population. The students of Decision Medicine came from different cities, high schools, backgrounds and even spoke different languages. Each student brought something unique to the

program and they all came together because of their dream to become physicians. As one of the students beautifully put it, “I am no longer just a student from Lincoln, or Linden or Franklin… I am a Decision Medicine student”. These future doctors are on a journey that will see them change lives and mold the future of our communities, cities, county and country as a whole.

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25 New

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Ma Abillar, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton CA Fac of Medical & Surg-University of Santo Tomas: 1996

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Rebecca Arthur, MD Obstetrics & Gynecology 999 S Fairmont Ave, Suite 225230 Lodi CA Office: 334-4924 Meharry Medical School: 2007

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Meeta Saxena, MD Family Medicine Kaiser Permanente 2185 Grant Line Road Tracy CA M P Shah Medical College: 1997

Savneet Kaur, MD Family Medicine Sutter Gould Medical Foundation 2185 Grant Line Road Tracy CA Office: 832-0535 Kasturba Medical College: 2002

Shermilla Shunmagham, MD Obstetrics & Gynecology Kaiser Permanente 1721 W Yosemite Ave Manteca CA Tirunelveli Medical College: 1991 Amardeep Singh, MD Cardiology Stockton Cardiology 415 E Harding Way, Suite D Stockton CA Office: 944-5750 University of Southern California: 2004

Brian Brice, MD Physical Medicine & Rehabilitation 422 E Hampton Street Stockton CA Office: 466-6898 University of California School of Medicine â&#x20AC;&#x201C; Davis: 1998

Tomislav Leskovar, MD Diagnostic Radiology Stockton MRI 2320 N California St, Suite 2 Stockton CA Office: 466-2000 Medical Fak Sveucilista U Zagrebu: 1986

Tia Curry, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton CA Washington Univeristy: 2008

Thao Nguyen, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton CA Chicago Medical School: 2008

Yu-Yea Tzeng, MD Obstetrics & Gynecology Kaiser Permanente 1721 W Yosemite Ave Manteca CA Office: 825-3555 University of Miami: 1995

Inderpreet Dhillon, MD Psychiatry Kaiser Permanente 7373 West Lane Stockton CA Office: 476-5188 National Medical University: 2002

Janessa Peralta, MD Pediatrics Kaiser Permanente 1721 W Yosemite Ave Manteca CA University of the Philippines: 1997

Sharon Wong, MD Internal Medicine Kaiser Permanente 1721 W Yosemite Ave Manteca CA Giuangzhou Medical College: 1984

Tijpal Randhawa, MD Cardiovascular Disease 1081 W March Lane, Suite D4 Stockton CA Office: 464-3615 Ross University: 2001

Charles Yang, DO Family Medcine Kaiser Permanente 7373 West Lane Stockton CA Midwestern University of Arizona College of Osteopathic Medicine: 1998

Victoris Hsu, MD Ophthalmology Central Valley Eye 36 W Yokuts Ave Stockton CA Office: 952-3700 Loma Linda University: 2005

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Elpidimonestor Iloreta, MD Family Medicine Kaiser Permanente 7373 West Lane Stockton CA University of Santo Tomas: 1991

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