October 2014

Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

Vital Signs

October 2014 • Vol. 36 No. 10

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2 OCTOBER 2014 / VITAL SIGNS

Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society Octoer 2014 Vol. 36 – Number 10

Contents EDITORIAL.................................................................................................................................5 CMA NEWS................................................................................................................................7 NEWS

HEALTHCARE REFORM............................................................................................................9

BLOOD CENTER: Blood Conservation Strategies......................................................................10

PLAN TO ATTEND: 34th Annual Cardiology Symposium.............................................................10

Editor Alan Birnbaum, MD

CLASSIFIEDS..........................................................................................................................15

Managing Editor Carol Rau Yrulegui

• President’s Message

• Save the Date: FMMS Gala Installation: November 19

• Walk with a Doc

• In Memoriam: E. Louis Janzen, MD

Fresno-Madera Medical Society Editorial Board Virgil M. Airola, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD Kings Representative TBD

Fresno-Madera Medical Society......................................................................................11

Kern County Medical Society...........................................................................................13

• Medical Missionary Journey: Part Three

• Save Date: K CMS Annual Award Membership Meeting: November 18 CMA Annual Session: December 5-7 KCMS Installation of Officers: January 16

• Membership News

Kern Representative John L. Digges, MD Tulare Representative Francine Hipskind Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medi­cal Society, PO Box 28337, Fresno, CA 93729-8337.

TULARE County Medical SocieTY.......................................................................................14

• Cenntral Valley Health Information Exchange

• Walk With A Doc

Advertising Contact: Display: Annette Paxton, 559-454-9331 apaxton@cvip.net Classified: Carol Rau Yrulegui 559-224-4224, ext. 118 csrau@fmms.org Vital Signs is published monthly by Fresno-Madera Medical Society.

Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials.

Questions regarding content should be directed to 559-2244224, ext. 118.

Oh cool, they’ll pay a fortune for this … heyyyy, hang on ... who says I have anti-social personality disorder!

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee OCTOBER 2014 / VITAL SIGNS

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Sponsored by:

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67136 (10/14) Copyright 2014 Mercer LLC. All rights reserved.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice.

The County Medical Associations and Societies/NORCAP/CMA receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

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EDITORIAL

How Your Hospitals Guard Patient Safety: Prop. 46 Measures Superficial and Punitive Alan M. Birnbaum, MD Editor, Vital Signs

Not only is that part of the proposition insulting to virtually every California physician, it largely duplicates powers that medical staff by-laws and structures already contain to allow assessment of potentially impaired or disruptive physicians.

In fact, the typical set of hospital regulations contains many safeguards, including those far more sophisticated than the sort of substance screening Proposition 46 advocates, which as we all know is as a screen for its partially hidden real purpose - encouraging medical malpractice litigation for the financial benefit of the plaintiffs’ bar.

Hospitals and physicians understand and value patient safety. For several Help Defeat Prop. 46: years, I have had the privilege of serving on a hospital’s Medical Staff Quality Register to Vote by Mail.

Committee (MSQC), chaired by a very capable and empathetic physician. Based Watch the mail for an on certain quality markers, occasionally from nursing staff concern and rather invitation to register to Vote rarely from patient or patient family complaints, cases receive systematic review by an experienced nurse. It then undergoes further review by a physician of the

by Mail. All physicians are appropriate specialty for a determination of “care appropriate” or for a minority urged to Vote NO on Prop. 46 of cases…not. and mail your ballot in early.

Every case that on initial review, rates “questionable” or “care not appropriate,” receives a full presentation at one of the monthly MSQC meetings, benefitting Early results are important, from additional input from committee members in varying specialties. Often, particularly during an the further discussion illuminates the issues and leads to a revision to “care election with low voter appropriate.” Or, specific questions to be asked of the involved physician, are turnout. drafted with the response assessed at a follow-up meeting.

In addition and in this fashion, every month dozens of hospital admissions with potential elements of adverse outcome and/or defective process, receive a full and impartial hearing in the spirit of the American principle of due process.

At times, serious problems or even troubling patterns do emerge, leading to recognition of physicians who suffer either from problematic personality issues that require formal intervention and correction or even uncover physicians in the early stages of a cognitive disorder.

Clearly, the “watchdogs” behind Proposition 46 do not understand that, or for their political purposes, do not want to fully understand the safeguards hospitals put into place.

So, as you the practicing physician “walk the precinct” with your patients and friends over the next few weeks leading up to November’s election, if and when one of them brings up the “safety” issue related to substanceimpaired physicians, do not fail to let them know that this represents only persiflage, diversion, and camouflage.

Also remember, as you walk your precinct inside your office and at social events with friends not directly involved in health care, make sure you reassure them that you and your colleagues value patient safety .

Requiring physicians to submit to random substance screening does nothing to effect that goal. It only diverts attention from the continuing critical core work of hospital quality assurance.

When discussing the safety issue, YOUR personal precinct should join you in voting NO on Proposition 46.

Author may be reached at Siriusguy @aol.com.

OCTOBER 2014 / VITAL SIGNS

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Stroke Conference Part II Agenda

You said what

to the Medical Board’s investigator?

Physicians often come to us after they have been interviewed by a Medical Board investigator or after they have already provided a written description of their care.

Did you know that a Medical Board investigator is a sworn peace officer, with a gun, and a badge, and the power to arrest you?

When the Medical Board demands an explanation, seek help immediately. The attorneys at Baker, Manock & Jensen have helped many physicians through the maze that is a Medical Board investigation. We would be honored to help you.

George L. Strasser 5260 North Palm Avenue Fresno, CA 93704 559 432-5400 gstrasser@bakermanock.com www.bakermanock.com

6 OCTOBER 2014 / VITAL SIGNS

8:00-8:30 Breakfast 8:30-8:45 Welcome and Joint Commission’s Performance Measures Program Director Trilok Puniani, MD 8:45-9:30 Unusual Causes of Stroke/Stroke Mimics Ann Bebensee, MD 9:30-10:15 Cardiogenic Stroke Muhammad Bajwa, MD 10:30-11:15 Inpatient Stroke Management Trilok Puniani, MD 11:15-12:00 Stroke Rehabilitation Muhammad Akbar, MD 12:15-1:00 Gaining Functional Independence and Transition to Community Marsa White, MD or Jonathan Wiens, MD (with lunch)

Objectives •D iscuss the different types of strokes and stroke rehabilitation • Review the standardized measures for Primary Stroke Center • Improve efficiency in administering TPA to patients with acute ischemic strokes NO CHARGE TO ATTEND RSVP deadline Oct 7 • call (559) 448-3319 or e-mail Marie.L.Smithey@kp.org The Kaiser Foundation Hospital, Fresno, is accredited by the Institute for Medical Quality/ California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. The Kaiser Foundation Hospital, Fresno takes responsibility for the content, quality and scientific integrity of this CME activity. The Kaiser Foundation Hospital, Fresno designates this educational activity for a maximum of 4 AMA PRA Category 1 Credit(s)™,.

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

This credit may also be applied to the CMA Certification in Continuing Medical Education.

Nurses may report up to 4 contact hours toward the continuing education requirements for license renewal by the California Board of Registered Nurses. Psychologists may report up to 4 contact hours toward the continuing education requirements for license renewal by the California Board of Psychology.

CMA NEWS CMA asks California Supreme Court to review case that could have far reaching implications on managed care contracting and payment for out-of-network services

The California Medical Association (CMA) and seven other physician

associations have filed an amicus letter brief urging the California Supreme Court to review a Fifth District Court of Appeals ruling that would dramatically lower the calculations of the reasonable and customary value for payment of out-of-network services and could have a huge negative impact on providers in managed care.

This case involves a dispute between Children’s Hospital Central California and Blue Cross of California and Blue Cross of California Partnership Plan, Inc. over the reasonable value of the post-stabilization emergency medical services provided by Children’s Hospital to Medi-Cal beneficiaries enrolled in Blue Cross’s Medi-Cal managed care plan. The services at issue were rendered during a 10-month period when Children’s Hospital and Blue Cross were in contract negotiations and did not have a written contract that covered those beneficiaries. The parties agreed that Blue Cross is required under the Knox-Keene Act to pay a rate that is reasonable and customary for the services, but they disagreed over how to determine that rate.

Children’s Hospital claimed the determination must adhere exclusively to Department of Managed Health Care regulations known as the “Gould factors.” The Gould factors require consideration of “(1) the provider’s training, qualifications, and length of time in practice; (2) the nature of the services provided; (3) the fees usually charged by the provider; (4) prevailing provider rates charged in the general geographic area where the services were rendered; (5) other aspects of the economics of the medical provider’s practice that are relevant; and (6) any unusual circumstances in the case.”

Blue Cross, on the other hand, argued that reasonable and customary must also consider the discounted contract rates that providers offer to accept from other payors as well as the reimbursement rates set by the government under Medi-Cal and Medicare.

The court of appeal agreed with Blue Cross in a published opinion.

CMA’s letter brief argues that the court of appeal’s opinion was founded on a fundamental misunderstanding of the out-of-network setting. Outof-network rates are measured as the reasonable and customary value of medical services, i.e., the free market value of those services. Contracted providers in a health plan’s network, by contrast, discount their rates in exchange for concrete in-network benefits and for numerous other reasons, including prompt payment, number of beneficiaries, utilization management, billing and administrative burden, health plan solvency and referral patterns.

Furthermore, Medi-Cal and Medicare reimbursement rates are subject to state budget constraints and other factors having nothing to do with the value of medical services. Discounted rates by in-network physicians and free market rates by out-of-network physicians are separate measures with separate underlying components. Yet the court of appeal’s opinion wrongly treats the two as comparable.

Legislature passes bill that would require annual reports from insurers on provider network adequacy

The legislature has passed a bill that would require Medi-Cal managed plans and insurers offering individual plans through Covered California to provide annual reports to the California Department of Managed Health

Care (DMHC) about the adequacy of their provider networks. The bill also requires DMHC to post annual reviews regarding plan compliance on its website.

This California Medical Association (CMA) supported the bill, SB 964 (Hernandez), and is now on the governor’s desk awaiting his signature.

Products that contain hydrocodone reclassified to Schedule II

The federal government published new rules that will govern hundreds

of medicines containing hydrocodone. These drugs will be reclassified as Schedule II substances, in line with oxycodone and morphine.

As Schedule II drugs, patients will be limited to up to a 90-day supply of medication and will have to see a provider to get a refill. (Under the Schedule III classification, a prescription could be refilled five times before the patient had to see a physician.) Physicians will not generally be allowed to call, fax or e-mail in a prescription to a pharmacy; instead, patients will have to present a written prescription.

California exceptions for emergencies and that apply to skilled nursing facilities, intermediate care facilities and hospice care remain in effect, and the reclassification will not impact the ability of physician assistants and nurse practitioners to write orders for hydrocodone products. The new rule will go into effect October 6, 2014.

‘Patient choice’ bill goes down to defeat in the Assembly

The California Medical Association (CMA) has defeated a bill that would have imposed unfair contracting conditions on physicians and exacerbated the state’s current network adequacy concerns. The bill (AB 2533) would have required health insurers to arrange for, or assist in arranging for, outof-network care for enrollees who are unable to obtain medically necessary care or services from a network provider, at no additional cost to the patient.

Unfortunately, vague language in the bill could have been interpreted to require out-of-network providers to accept the contract reimbursement rates of the plan, and it explicitly prohibited them from billing enrollees for any amount in excess of the in-network reimbursement rate.

Optometrist scope bill dead this session

The California Medical Association (CMA) has successfully quashed

a scope-of-practice bill (SB 492) that originally would have allowed optometrists to diagnose and treat any disease with an ocular manifestation.

CMA was able to get most of the egregious language in the bill stripped leaving only provisions that would have allowed optometrists to administer flu and shingles vaccines. The author of the bill Sen. Ed Hernandez signaled that he would not push the bill forward for a vote on the Assembly floor. It is now in the Assembly inactive file.

CMA would like to thank all the physicians who took time to call, write and fax their legislators to oppose the bill.

What can pharmacists do under their newly expanded role as health care providers?

In 2013, the California Legislature enacted SB 493, which clarified the pharmacist’s role as “health care providers,” expanded the ability of pharmacists to provide health care services and established an “advanced practice pharmacists” recognition, allowing qualified pharmacists to engage in additional activities.

Please see CMA News on page 8 OCTOBER 2014 / VITAL SIGNS

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CMA NEWS

Where Do Your Reports Come From?

Continued from page 7

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As part of their expanded roles, pharmacists may now furnish self-administered hormonal contraceptives and specific nicotine replacement products with additional training and in accordance with approved protocols and procedures. They can also furnish medications recommended by the Centers for Disease Control and Prevention for individuals traveling outside of the United States. Additionally, pharmacists may administer routine vaccines recommended by the federal Advisory Committee on Immunization Practices for persons three years of age and older following additional training.

In addition, SB 493 establishes that an advanced practice pharmacist may perform patient assessments, order and interpret drug therapy-related tests in coordination with the patient’s primary care provider or diagnosing prescriber, refer patients to other health care providers and participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers.

CME certification now available online 231 W. Fir Avenue, Clovis

www.sierraimaging.org

8 OCTOBER 2014 / VITAL SIGNS

559.297.0300

Scheduling 559.322.4271

Users of the CME certification service offered by the California Medical Association’s (CMA) Institute for Medical Quality (IMQ) are now able to check the status of CME credits, keep track of their progress and print their transcripts at their convenience from IMQ’s online CME certification user portal.

Physicians are required to complete 50 CME hours during every two-year licensure period, with reporting deadlines based on the physician’s personal license renewal date (the last day of the month of the physician’s birthday).

IMQ’s CME Certification Program documents and verifies physicians’ CME activities. When certified by IMQ , physicians’ CME credits will automatically be accepted by the California Medical Board, saving you time and hassle. (IMQ also provides documentation of physicians’ CME in the event of a medical board audit.)

IMQ’s CME certification is $30 for CMA members, $55 for nonmembers. Physicians also can request that their CME certification information be sent to hospitals, health plans, specialty societies, and others for credentialing or membership renewal purposes at no additional charge.

For more information, visit the IMQ website.

HEALTHCARE REFORM More CalifORNIA Health Care Providers Offering Access to Patient Portals

Patients and caregivers across California are seeing “dramatic changes” in the health care industry as more physicians provide access to online patient portals, HealthyCal reports.

The portals are available to patients 24 hours per day and usually include: • A summary of basic health history, including allergies, medical conditions and prescriptions; • A tool to pay medical bills; • A tool to schedule appointments or refill prescriptions; • Lab results; and • Secure messaging capabilities.

For the most part, physicians’ concerns about the portals – such as losing in-person time with patients because of responding to excessive or unnecessary communications through the portal – have not come to pass, according to HealthyCal. Despite advances in the use of patient portals across California, some physicians have reported issues with using the technology.

For example, some providers had patients send them multiple messages through a portal’s secure communication tool that were excessively long or unrelated to medical care. Some doctors also have voiced concerns that patients will use the portals instead of obtaining in-person care.

In addition, portals are not available in languages for all of the varied demographics across the state. Michelle Quiogue, a physician in Bakersfield, said expanding patient portals to include Spanish should just be the first step in making the technology available to the state’s diverse population (Schmitt, HealthyCal, 9/3).

Analysis: More CalifORNIA Children Obtaining Vaccine Exemptions

An increasing number of kindergarten students in California are obtaining exemptions to avoid receiving state-mandated vaccinations – a trend that experts say could increase the risk of disease outbreaks, according to an analysis of state Department of Public Health data by the Los Angeles Times.

Experts say that epidemics can become a risk when 8% or more of kindergarteners do not obtain vaccinations. According to the Times analysis, the rate of personal belief exemptions in the state increased from 1.5% in 2007 to 3.1% in fall 2013.

An increase in the number of personal belief exemptions is particularly apparent among private schools. Nearly 25% of private-school kindergartens reported that 8% or more of their students filed such exemptions last year for at least one vaccine, compared with 11% of public schools (Esquivel/ Poindexter, Los Angeles Times, 9/2).

Brown Signs Bills Increasing Access to EpiPens, Overdose Drug

Gov. Jerry Brown (D) has signed into law two bills that will require California school districts to stock emergency epinephrine auto-injectors, or EpiPens, and will increase the availability of naloxone – a drug that commonly is used to reverse respiratory depression caused by overdosing on painkillers.

The California Teachers Association, California School Employees Association and California Federation of Teachers opposed the measure (California Healthline, 5/27).

According to Food Allergy Research & Education, a sponsor of the bill, about two students in every U.S. classroom have been diagnosed with dangerous allergies (Central Valley Business Times, 9/16).

AB 1535, by Assembly member Richard Bloom (D-Santa Monica), will make naloxone available without a prescription at pharmacies across the state to help treat opiate overdoses.

The drug, which is available as a nasal spray or injectable medication, has been used for decades by emergency department physicians and paramedics (California Healthline, 9/3). The new law, which takes effect Jan. 1, 2015, will allow pharmacists to give the medication directly to drug users or their family members.

California’s pharmacy and medical boards will develop guidelines for when and how to dispense the drug. In addition, the law mandates training and education for both pharmacists and consumers.

Obama Administration Delays Some Meaningful Use Requirements

Last month, CMS announced in a final rule that it will delay some requirements of the meaningful use program, allowing health care providers to continue receiving incentive payments if they have not yet adopted electronic health records software that was certified in 2014, The Hill reports (Viebeck, The Hill, 8/29).

Under the delay, participating providers are now permitted to use EHR systems that were certified in 2011, or a combination of 2011- and 2014-certified technologies, until 2015. In 2015, all providers must begin to use only 2014-certified technology (Monegain, Healthcare IT News, 9/2). Providers will not be penalized for failing to move to meaningful use Stage 2 (The Hill, 8/29).

The proposed rule acknowledged that many software vendors have had difficulty upgrading their EHR products, receiving certification and upgrading customers’ systems in time to attest to the meaningful use program (California Healthline, 5/21).

The final rule did not change any of the proposed rule’s provisions (Modern Healthcare, 8/29).

More Data To Be Withheld from CMS’ Open Payments System

The CMS Open Payments System will not include records of research

grants that drugmakers make to physicians through intermediaries when the site goes public on Sept. 30, ProPublica reports (Ornstein, ProPublica, 8/28).

The Open Payments System, which is required under the Affordable Care Act’s Sunshine Act, aims to boost transparency by making public what payments health care providers have received from drugmakers and medical device manufactures. CMS said that about one-third of CMS Open Payments Systems records will be withheld when the system launches because of data inconsistencies (California Healthline, 8/18).

CMS also has not yet answered several other questions about the Open Payments System, including: • How consumers searching the Open Payments System will be notified when data are withheld; • The number of records reported by companies; • The number of total records being withheld; • The number of companies that reported incorrect data; and • W hich submitted data are flawed.

CMS previously had indicated that it would not release withheld data to the public until June 2015, according to ProPublica (ProPublica, 8/28).

Please see Healthcare Reform on page 12 OCTOBER 2014 / VITAL SIGNS

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BLOOD CENTER Blood Conservation Strategies Lead to Less Transfusion with No Impact on Mortality Patrick C. Sadler, MD, Medical Director, Central California Blood Center

Over the past several years, there has been a growing movement in healthcare toward the use of blood

conservation strategies – also called patient blood management (PBM) – to improve patient outcomes, reduce unnecessary transfusion, and cut costs.

A recently published analysis of medical record data for more than 300,000 patients showed that the incidence of red blood cell (RBC) transfusion decreased broadly among medical and surgical patients with no impact on 30-day mortality following the implementation of blood conservation strategies in a large hospital system.

Several studies have shown that PBM can lead to a drop in blood use and unnecessary transfusion, with randomized clinical trials in specific patient populations suggesting that a restrictive transfusion strategy leads to similar or improved patient outcomes when compared with a liberal one. However, there are limited data regarding the impact of blood conservation practices in diverse patient populations.

In the current study, published in Transfusion, Nareg H. Roubinian, MD, of Blood Systems Research Institute, and colleagues of the NHLBI Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) conducted a retrospective review of medical records from 21 medical facilities in Kaiser Permanente Northern California (KPNC) to examine trends in RBC utilization and mortality across varied medical and surgical groups.

KPNC implemented a range of blood conservation strategies from 2010 to 2012, including transfusion education for clinicians, blood utilization guidelines, cell salvage techniques, and an electronic decision support system integrated into the transfusion order sets. To assess the impact of these techniques, the researchers examined 30-day mortality and RBC transfusion incidence in 391,958 patients who experienced 685,753 hospitalizations from 2009 to 2013. During this time, the transfusion rate decreased from 14 to 10.8 percent of hospitalizations, and the pre-transfusion hemoglobin level dropped from 8.1 to 7.6 g/dL. “This reduction occurred across all KPNC facilities and was associated with decreased interhospital variability in inpatient transfusion rates. Declines in the number of RBC units transfused and the pretransfusion hemoglobin levels were seen broadly in medical and surgical inpatients, as well as in subgroups of patients with and without clinical trial data to support restrictive transfusion strategies,” wrote the authors.

They add that there was no impact on 30-day mortality associated with decreased blood use or restrictive transfusion practices. The biggest declines in RBC use were seen in populations for whom strong clinical data support restrictive transfusion strategies, among whom no change in 30-day mortality was observed.

“Our data support the safety of broad application of clinical trial-based [restrictive transfusion] recommendations in a diverse community hospital population,” concluded the authors. However, they note that it is possible that a small effect on mortality could have gone undetected in this study due to the myriad of other factors that also affect mortality.

The authors suggest that additional studies are necessary to assess whether further reductions in RBC use and hemoglobin thresholds in large cohorts and unstudied subgroups have an impact on morbidity and mortality.

(Source: ABC Newsletter, September 5,2014.) (Citation: Roubinian NH, et al. Trends in red blood cell transfusion and 30-day mortality among hospitalized patients. Transfusion. 2014 Aug 18. [Epub ahead of print]

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PLAN TO ATTEND 34th ANNUAL CENTRAL VALLEY CARDIOLOGY SYMPOSIUM November 8, 2014 TorNinos’ Banquet Hall, Fresno 8:00am to 3:30 pm FEATURED TOPICS AND SPEAKERS Defining & Redefining Myocardial Infraction in the Era of High Sensitivity Troponins CT Angiography vs. MR Angiography in Advanced Cardiovascular Diagnosis Adult Congenital heart Diseases: Understanding the Past to Plan for Future Objectives Pregnancy & the Adult with Congenital Heart Diseases – A World of Change for Mother & Fetus Sex-Specific Diagnostic Approaches in Evaluating Symptomatic Women with Obstructive CAD Hormonal Therapy Controversies in Perimenopausal Women John Ambrose, MD, FACC Professor, Chief of Cardiology, UCSF-Fresno Paul Francis, MD Professor, Chief of Pediatrics, UCSF-Fresno Chandra K. Katikireddy, MD Assistant Professor; Cardiac Imaging Section, UCSF-Fresno Puja K. Mehta, MD, FACC Director, Research Lab, Barbra Streisand Women’s Heart Center Cedars-Sinai Heart Institute, Los Angeles No charge: FMMS members, Retired MDs, Medical students, Interns, Residents & Fellows $75 Physicians $45 Allied Professionals Information: 559-224-4224 x 118 or csrau@fmms.org Accreditation Statement: The FresnoMadera Medical Society (FMMS) is accredited by the Institute for Medical Quality/ California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.

Credit Designation Statement: The FMMS designates this live activity for a maximum of 6 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This credit may also be applied to the CMA certification in Continuing Medical Education.

Fresno-Madera PRAHALAD JAJODIA, MD

President’s Message CURES’ Website Won’t Meet Prop. 46 Mandate Yet – Another Reason to Vote No on 46

A State staffer in charge of the CURES Database testified that the system is “not sufficient” and “does not know” if it will be functional as required by the ballot measure.

Last month the statewide coalition opposed to the deeply flawed Proposition 46 released a video underscoring the numerous problems with the state-run prescription-drug database that physicians and pharmacists would have to consult under Proposition 46. The concerns were voiced in recent testimony by the state expert charged with overseeing the glitch-plagued website.

Under Proposition 46, starting the day after the November 2014 election, physicians and pharmacists will be required to consult the Controlled Substance Utilization Review and Evaluation System (CURES) database before prescribing certain medications. Physicians who do not comply will be presumed negligent.

By all accounts, CURES does not have the capacity to handle the additional traffic generated by Proposition 46.

Under legislation passed in 2013, some upgrades to the system are expected, but not until the summer 2015 at the earliest – months after the Proposition 46 mandate would kick in.

This “CURES mandate flaw” puts physicians in the untenable position of either breaking their Hippocratic Oath or breaking the law.

On July 24, 2014, in testimony before the California Medical Board, the state staff person in charge of CURES – California Department of Justice staffer Mike Small – repeatedly made clear that the database will not be adequate or fully functional until mid-2015 at the earliest.

Below are transcribed highlights of Small’s presentation, taken from the video that was posted on You Tube: Small describing the current CURES system: • “It has proven one thing unquestionably – that it is not robust enough, it is not sufficient enough to carry out the mission that we need…”

• We’ve been unable to answer phone calls in a timely basis • 5-6 week backlog to process the practitioner’s application • If I tried as hard as I can to build a terrible system, I don’t think I could meet this Asked how long it takes for a registered user to get a response from CURES: “I’m not going to give you any one firm time, but usually in the existing system it could be anywhere from moments to never. ” Asked if CURES 2.0 will operate in real time: “No. In the sense that real time is real time ingestion of data, processing, and making it available; if we have legislation that only allows us to accept (data) every 7 days at the max, we cannot possibly have a real time system, even if we plan for it.”

Post Office Box 28337 Fresno, CA 93729-8337 1040 E. Herndon Ave #101 Fresno, CA 93720 559-224-4224 Fax 559-224-0276 website: www.fmms.org Officers Prahalad Jajodia, MD President A.M. Aminian, MD President-Elect Hemant Dhingra, MD Vice President Ahmad Emami, MD Secretary/Treasurer Ranjit Rajpal, MD Past President Board of Governors Alan Birnbaum, MD S.P. Dhillon, MD William Ebbeling, MD Anna Marie Gonzalez, MD David Hadden, MD Joseph B. Hawkins, MD Sergio Ilic, MD Alan Kelton, MD Trilok Puniani, MD Khalid Rauf, MD George Saul, MD Roydon Steinke, MD CMA Delegates FMMS President Don Gaede, MD Michael Gen, MD Brent Kane, MD Brent Lanier, MD Kevin Luu, MD Andre Minuth, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-Elect Perminder Bhatia, MD Praveen Buddiga, MD Surinder P. Dhillon, MD Trilok Puniani, MD Oscar Sablan, MD CMA Trustee District VI Virgil Airola, MD Staff Sandi Palumbo Executive Director

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Fresno-Madera Kings E. Louis Janzen, MD 52-year member

Fresno-Madera Medical Society PHYSICIANS: Looking for ways to: • Add more physical activity to your lifestyle?

• Be a role model and inspiration to your patients and your community?

• Spend more time with your family and friends?

Consider volunteering ONE HOUR every month or two in the Fresno-Madera Medical Society’s: WALK WITH A DOC Program This walking program is risk free and requires no preparation. Physicians just need to: SPEND A SATURDAY MORNING: •P resenting a 2-3-minute presentation on the health benefits of walking from the perspective of your specialty • Leading a 45-50 minute walk around Woodward Park in Fresno or Town & County Park in Madera • Answering potential questions from the walkers Encourage patients to take steps to improve their health

FRESNO: OCTOBER 25

Woodward Regional Park Sunset View Shelter Registration 8:45am Walk Event 9am-10am

MADERA: OCTOBER 4

Town & Country Park Pavilion Area Registration 8:15am Walk Event 8:30am-9:30am

E. Louis Janzen, MD, a retired pediatrician, passed away on Aug. 25, 2014 at the age of 82.

Dr. Janzen received his medical degree at Northwestern Medical School in Chicago in 1957. He completed his internship at Los Angeles County General Hospital and his residency at Tulare County and Los Angeles County general hospitals.

He began his private practice in Fresno in 1962 and retired in 1998. Dr. Janzen is survived by his wife, four children and seven grandchildren.

Healthcare Reform Continued from page 9

New Law Extends the Time Doctors’ Disciplinary Records Stay Online

Last month, , Gov. Jerry Brown (D) signed a bill (AB

1886) that requires the Medical Board of California to extend the amount of time that information on certain serious disciplinary actions against doctors remains available online, the Sacramento Business Journal reports.

The bill was amended after the California Medical Association expressed concerns about provisions that would have required less serious disciplinary actions to be posted indefinitely. In response, lawmakers changed the bill to: • Reduce the amount of time citation information is available online from 10 years to three years; and • Reduce the amount of time malpractice settlement information is available from 10 years to five years.

Records that have been removed from the site but now meet the standards under the bill will be reposted, according to the Business Journal (Robertson, Sacramento Business Journal, 8/26).

PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 Officers Jeffrey W. Csiszar, MD President Vacant President-Elect Mario Deguchi, MD Secretary Treasurer Theresa P. Poindexter, MD Past President Board of Directors Bradley Beard, MD James E. Dean, MD Thomas S. Enloe, Jr., MD Ying-Chien Lee, MD Uriel Limjoco, MD Michael MacLein, MD Kenny Mai, MD CMA Delegate Ying-Chien Lee, MD Staff Marilyn Rush Executive Secretary

Ready to Volunteer?

For a schedule of dates and times Call the FMMS office: 559-224-4224x110 or send email to receptionist@fmms.org

A COSTLY THREAT TO YOUR PERSONAL PRIVACY CALIFORNIANS CAN’T AFFORD Find us on Facebook: Fresno-Madera Medical Society

www.facebook.com/pages/Fresno-MaderaMedical Society/107731015917068

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Kern Guest Editorial

Medical Missionary Journey Thomas R. Larwood, MD with Portia Choi, MD PART III The history of Severance Hospital reflected the history of medical missionary work in Korea by Americans. Severance Hospital evolved from the first modern medical facility in Korea that was established by Horace Newton Allen, a missionary doctor sent to Korea by the Board of Foreign Missions of the Presbyterian Church. He was born in Delaware, Ohio on April 23, 1858. He received his B.S. at Ohio Wesleyan University in 1881 and subsequently graduated from Miami Medical School, Cincinnati, Ohio in 1883. Soon after his arrival with his family in September of 1884, he was involved in the aftermath of Gapsinjeongbyeon to overthrow King Gojong. During the fighting a royal relative, Min Young Ik, was stabbed. Prince Min Young Ik was a former envoy to the United States and nephew of Queen Min. The German diplomat Paul Georg von Möllendorff was present at the massacre and quickly requested Allen’s medical care for the prince. Under his modern medical treatment, unknown to Korea at the time, Min Young Ik recovered in three months. This initiated for Dr. Allen a close connection with King Gojong who was the twenty-sixth king of the Korean Joseon Dynasty and the first emperor of the Korean Empire. Dr. Allen demonstrated the benefit of western medicine to the Korean public. With this auspicious turn of events Dr. Allen was able to establish the Royal Hospital Gwanghyewon (House of Extended Grace) under royal finance and support in Seoul. Gwanghyewon was the first modern medical facility in Korea. The Gwanghyewon was soon renamed by the Emperor to Chejungwon (the House of Universal Happiness). In 1886, Chejungwon Medical School, Korea’s first modern medical school was founded.

Dr. Allen was instrumental in lifting the nation’s anti-Christianity policy to allow the influx of missionaries to evangelize, build schools and other western hospitals in Korea.

The Chejungwon hospital grew, and by 1899 it was determined that a new facility had to be erected. It was at the Ecumenical Missionary Conference in New York in 1900 that Louis H. Severance, an American philanthropist in the audience, first heard of the need for a modern hospital in Seoul. He had been hoping to fund a project of the sort and decided that Seoul would be an ideal place for his donation. The hospital was completed in September of 1904 and was named Severance Memorial Hospital.

The history of Korean belief in one God (hananim) led to about half the population becoming Christian by the 1950s; unique in Asia, except in the Philippines, where Catholicism had been introduced during the 16th century.

Authors can be reached at trlarwood@bak.rr.com or ssportia@aol.com.

References on Dr. Horace Newton Allen and Severance Hospital are taken from New World Encyclopedia and Yonsei University Health System websites.

This article was first printed in the Levan Humanities Review, Volume 2, Issue 1 (2014) and is available on-line by Googling Levan Humanities Review.

SAVE THESE DATES • Tuesday, November 18, 2014: KCMS Annual Awards Membership Meeting, Padre Hotel • Friday, December 5-7, 2014: CMA Annual Session, San Diego Marriott Marquis & Marina

2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website: www.kms.org Officers Alpha J. Anders, MD President Michelle S. Quiogue, MD President-Elect Eric J. Boren, MD Secretary Bradford A. Anderson, MD Treasurer Wilbur Suesberry, MD Past President Board of Directors Alberto Acevedo, MD Lawrence N. Cosner, Jr., MD Vipul R. Dev, MD John L. Digges, MD Susan S. Hyun, MD Kristopher L. Lyon, MD Ronald Morton, MD Mark L. Nystrom, MD Edward W. Taylor, III, MD CMA Delegates Jennifer Abraham, MD Vipul Dev, MD John Digges, MD Lawrence N. Cosner, Jr., MD Staff Sandi Palumbo Executive Director Kathy L. Hughes Administrative Assistant

• Friday, January 16, 2015: KCMS Installation of Officers, The Bell Tower

WELCOME KMC RESIDENT PHYSICIAN MEMBERS

WELCOME KAISER PHYSICIAN MEMBERS

ADAMS, Ninos (PSY) AMMAR, Ali (IM) ANSARI-Pirsaraei, Pedram (IM) ASSEM, Sarah (IM) CHAHAL, Rajinder (IM) CHIQUILLO-Sosa, Rafael (FM) GHOLAM, Samiollah (IM) GILL, Sandeep (PSY) HAMMAMI, Mohamed (IM) MUSTAFA, Nada (IM) PALACIOS, Fernando (FM) ROMERO, Adan (FM) TALWAR, Rishi (IM)

ABARY, Rosanna (PD) BENNETT, Lindsey (D) CANSON, Earl (FM) HU, Jennifer (OPH) JURICH, Daniel (IM) JURICH, Jorieth (IM) MANGAT, Amolika (IM) MANGAT, Geeteshwar (IM) NANDYAL, Deepa (CD/IM) TRAN, Juliane (PMR) TAZEN, Sirinan (N) WINTER, Trevor (GE) OCTOBER 2014 / VITAL SIGNS

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Tulare Central Valley Health Information Exchange: Coming Soon to Our Region 3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website: www.tcmsonline.org Officers Thomas Gray, MD President Monica Manga, MD President-Elect Virinder Bhardwaj, MD Secretary/Treasurer Steve Cantrell, MD Past President Board of Directors Anil K. Patel, MD Carlos Dominguez, MD Pradeep Kamboj, MD Christopher Rodarte, MD Antonio Sanchez, MD Raman Verma, MD CMA Delegates Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates Robert Allen, MD James Foxe, MD Mark Tetz, MD Sixth District CMA Trustee Ralph Kingsford, MD Staff Francine Hipskind Executive Director Thelma Yeary Executive Assistant Dana Ramos Administrative Assistant

Alzheimer’s Association Walk to End Alzheimer’s Saturday, October 4, 2014 Mooney’s Grove Park All proceeds benefit the Alzheimer’s Association.

For information, visit: www.alz.org/socal or call (323) 930-6228

Lynne Ashbeck, Regional Vice President, Hospital Council Rob Pokelwaldt, Project Manager, CVHIE

The Affordable Care Act (ACA), among its many provisions, has called for the creation of ‘data exchanges’ to enable

providers to share patient data to improve care, care coordination, and, ultimately, patient outcomes. Much has been written about efforts in communities across the country…clearly some more successful than others… to establish a means by which physicians, hospitals, labs and other providers can share relevant data to improve care coordination, reduce duplicative tests/procedures and effectively manage the care of the patients we all share.

Is it possible to create such an exchange in the Valley?

Since mid-2012, the Hospital Council of Northern and Central California has led a series of stakeholder meetings and work groups comprised of physicians, hospitals, clinics and others in the Fresno-Madera-Tulare-Kings region to achieve just that goal.

After much work, the Central Valley Health Information Exchange (CVHIE) was officially launched in October 2013 to provide physicians, hospitals, clinics and other healthcare providers in California’s Central Valley with access to a state-of-the-art electronic health records network. After a thorough vendor search, CVHIE will enable participating members to securely share electronic patient health records through a network developed by Inland Empire Health Information Exchange, using the integration platform of Orion Health Collaborative Care.

Participation in CVHIE will also help attain the Meaningful Use Stages I and II certifications called for in the ACA. CVHIE’s initial membership includes 14 provider organizations, including: • Children’s Hospital Central California • Madera Community Hospital • Clinica Sierra Vista • San Joaquin Valley Rehabilitation Center • Coalinga Regional Medical Center • Sierra View Local Health Care District • Community Medical Centers • St. Agnes Medical Center • Family Health Care Network • Tulare Community Health Clinic • Kaweah Delta Health Care District • Tulare Regional Medical Center • Key Medical Group • Visalia Medical Clinic What benefits will my practice see from HIE? Appropriate and timely sharing of patient information can improve provider workflow and care quality in many ways. While some of this information sharing is happening already via fax machine and other paper-based methods, electronic sharing of information vastly improves efficiencies and expands the quality and depth of data pooled among trusted providers. The digital exchange of health information means providers have at their fingertips a fuller picture of their patients’ overall health status. This can include patient medical histories, current prescriptions and allergies, and recent laboratory test results and immunizations. Below are just a few examples of how the electronic sharing of health information can benefit your practice.

• E xchange real-time clinical information among providers • View consolidated clinical data such as demographic details, patient alerts, allergies, abnormal test results, encounter details, medications and immunizations all from one screen • Receive electronic alerts and notifications on your patients direct to your messaging inbox, e-mail account, iPhone, or EMR system • Process diagnostic laboratory and radiology orders online (EMR Lite) • Provide patients access to view their clinical record online • Reduce re-admissions through better care transitions • Create case management care plans for patients with chronic conditions such as diabetes and asthma • Electronically transmit prescriptions (EMR Lite) • Eliminate redundant medical testing • View radiology and PACS images online, linked to the patient record • Submit immunizations/syndromic surveillance/lab data to public health How will CVHIE expand beyond the founding members?

Our goal is to include as many healthcare providers in CVHIE as possible. Joining our group since its launch have been local public health departments (who are interested in the Syndromic surveillance capabilities); local emergency Please see CVHIE on page 15

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Tulare

CLASSIFIEDS

CVHIE

Tulare County Medical Society presents

Continued from page 14 medical service agencies (for the ability to monitor the impact of pre-hospital care); private physician offices (those not affiliated with a particular hospital); and additional rural health clinics. The more participants in CVHIE, the more robust and useful the data will be to all involved.

Is the investment to participate in the CVHIE worth it?

Currently, the cost structure for CVHIE includes fees to cover both the technology functions and a small administrative fee to cover internal program costs. Costs per participant are very low given the volume of providers we have engaged in this effort. The cost structure is based on a per bed calculation for hospitals and a per physician cost for clinics and private practices.

For more information on participation/costs, please contact Rob Pokelwaldt, Project Manager for CVHIE at rob.pokelwaldt@gmail.com, or Lynne Ashbeck, Regional Vice President, Hospital Council at lashbeck@hospitalcouncil.net.

­­Members: 3 months/3 lines* free; thereafter $20 for 30 words.

NON-Members: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.

FRESNO ANNOUNCEMENTS

Join us at the next Walk With A Doc to take a step toward a healthier you!

All you need to do is lace-up a pair of comfortable shoes and join us for some fresh air, fun and fitness.

TULARE: Del Lago Park Saturday, October 25, 2014 8:00am to 9:00am VISALIA: Riverway Sports Park Saturday, October 11, 2014 8:00am to 9:00am

Dr. Paul James Nugent earned in May, 2014 his Masters in Public Health at UC Berkeley and will use this knowledge to deliver innovative care to spine & orthopedic patients, focusing on elaborating “up stream” negative social determinants effecting physicians’ health..

University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5pm. Call 559-3200580.

PHYSICIAN WANTED .

Spruce Multispecialty Group of Fresno, committed to the private practice of medicine, is recruiting a BE/BC IM, Rheumatology or Pulmonary specialist. Contact Rathin at 559-289-9518 or tharathin@gmail.com.

Anyone can attend!

For more information, please contact Tulare County Medical Society at (559) 627-2262

New Career Opportunities Available

Gar McIndoe (661) 631-3808 David Williams (661) 631-3816 Jason Alexander (661) 631-3818

MEDICAL OFFICES KERN

FRESNO

FAMILY MEDICINE FACULTY

FAMILY MEDICINE FACULTY

Clinica Sierra Vista is seeking a Board Certified Family Medicine Physician to serve as faculty for the Rio Bravo Family Medicine Residency Program. Full and part-time teaching positions available!

Make a difference in the lives of new physicians and join our faculty! Inpatient and Obstetrics a plus! Competitive salary offered.

Federal loan forgiveness may be available for qualified applicants.

Clinica Sierra Vista is seeking a Board Certified Family Medicine Physician to serve as faculty for the Sierra Vista Family Medicine Residency Program. Full and part-time teaching positions available!

Make a difference in the lives of new physicians and join our faculty! Inpatient and Obstetrics a plus! Competitive salary offered.

Federal loan forgiveness may be available for qualified applicants.

Interested applicants may contact Clinica Sierra Vista

(661) 979-0812

FOR LEASE 8327 Brimhall – 1,629 rsf.

8327 Brimhall – 2,288 rsf.

Crown Pointe Phase II – 2,000-9,277 rsf.

3115 Latte Lane – 5,637 rsf.

3115 Latte Lane – 2,660-2,925 rsf.

1150-1160 Lerdo Hwy, Shafter 1,766 to 3,793 sf.

9300 Stockdale Hwy. – 16,618 sf.

9330 Stockdale Hwy. – 5,754 rsf.

9900 Stockdale Hwy. – 2,085 sf.

2019 21st Street – 2,856 sf.

SUB-LEASE 4100 Truxtun Ave. – Adm. & Billing – 6,613 rsf.

FOR SALE 3015 Calloway – 1,465-10,318 sf.

4939 Calloway #103 – 1,827 sf.

Crown Pointe Phase II – 2,000-9,277 rsf.

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VITAL SIGNS Post Office Box 28337 Fresno, California 93729-8337

PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30

HAVE YOU MOVED? Please notify your medical society of your new address and phone number.

Proud to be endorsed by the Fresno-Madera, Kern, Kings and Tulare County Medical Societies

Our mission begins and ends with you, the policyholder.

That means connecting our members to the highest quality products and services at the lowest responsible cost. Join us as we enter a new phase of our journey and advance with our vibrant new look and expanding offerings.

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