April 2009 by San Diego Physician

official publication of the san diego county medical society • April 2009

Health information

technology

SDCMS and ama candidate statements P.16 Polst form now available in california P.20 Interview with kindred hospital ceo P.22 hero for a day P.44

“ PHYSICIANS UNITED FOR A HEALTHY SAN DIEGO ”

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The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety. In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer. And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look out for the doctor is to start with the patient. To learn more about our medical professional liability program for San Diego County Medical Society members, call (858) 452-2986 or visit us at www.thedoctors.com.

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Contents VOL. 96 | NO. 4

Health Information Technology • Electronic Health Record Buyers, Beware • SDCMS E-prescribing Resources • AMA Explains the ARRA’s HIT Provisions • HIT Stimulus Could Bring $3 Billion in New Funds to California • The Infobutton: Knowledge-based System Meets EHR • Electronic Records Would Improve Americans’ Health (Web Exclusive) • The Internet: Friend or Foe to Physicians? (Web Exclusive)

[Departments]

4 6 8 10 12 16 20

Contributors

This Issue’s Contributing Writers

Editor’s Column

The Secret Sauce of Office Practice Redesign

SDCMS’ 2009 Seminars and Events Community Healthcare Calendar Ask Your Physician Advocate SDCMS BOD and AMA delegate 2009 Election Candidate Statements

Bioethics

22 24 26 40 41 44

Interview

With Kindred Hospital CEO Natalie Germuska

County Public Health Officer’s Update

Place Matters to Your Patients’ Health

Technology matters

Cloud Computing and Healthcare

Physician Marketplace Classifieds

Volunteer

With SDCMSF’s Project Access San Diego

Hero for a Day

Boy Slices His Wrist on His Snowboard

Physician Orders for Life-sustaining Treatment (POLST) Forms

[ w e b e x cl u s i v e ] The Coming of Age of Phlebology: New Interest in an Old Condition by Nisha Bunke, MD

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More than a healthcare professional, you are a trusted partner in your patients’ health. So are we. Beyond providing outpatient diagnostic imaging services, we’re here to help you improve the health of your community. How? By becoming, like you, a true and trusted partner in patient care. And as your partner, we’ll work to improve your patient outcomes as well as satisfaction. That means helping you diagnose diseases and disorders safely, quickly and accurately, so that you can begin treatment sooner. We also understand that no two patients are alike. We’ll help you treat the individual needs of unique patient populations, including athletes and the physically disabled. Along with prompt, patient-friendly customer service, we also provide convenience—with 15 San Diego area locations and contracts with most insurance companies. Making it easier for your patients to get the care they need. From the professionals they trust. So here’s to your patients’ health. And to the start of a long and healthy partnership. Contact Imaging Healthcare Specialists today.

Contributors AMERICAN MEDICAL ASSOCIATION (AMA) AMA’s mission is to promote the art and science of medicine and the betterment of public health. Its core values include leadership, excellence, integrity, and ethical behavior. Its vision is to be an essential part of the professional life of every physician. AMA helps doctors help patients by uniting physicians nationwide to work on the most important professional and public health issues.

RICHARD A. BROWN, MD Dr. Brown, SDCMS and CMA member since 1993, is board certified in both surgery of the hand and orthopedic surgery. He is a member of Torrey Pines Orthopaedic Medical Group, Inc. CALIFORNIA HEALTHCARE FOUNDATION The California HealthCare Foundation (CHCF) is an independent philanthropy committed to improving the way healthcare is delivered and financed in California. By promoting innovations in care and broader access to information, CHCF’s goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford.

Stephen H. Carson, MD Dr. Carson, SDCMS and CMA member since 1983, has for the past 25 years served as a consultant for health systems, schools of medicine, health plans, hospitals, and medical groups. In 1992, Dr. Carson founded Primary Care Associates (PCA), an independent practice association of 80 primary care physicians and more than 300 specialists serving the north coastal region of San Diego County. Dr. Carson served as the chief medical officer for the San Diego County Medical Society Foundation from 2005 through 2008. He continues to practice pediatrics and pediatric pulmonary medicine in Hillcrest.

Lynette Cederquist, MD Dr. Cederquist, SDCMS and CMA member since 2005, co-chairs SDCMS’ Bioethics Commission.

Marisol Gonzalez Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership. Joseph E. Scherger, MD, MPH Dr. Scherger, SDCMS and CMA member since 1993, is clinical professor of family medicine at UC San Diego. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

Ofer Shimrat Mr. Shimrat is founder and CEO of SDCMS-endorsed Soundoff Computing Corporation, a consultancy specializing in IT products and services. Originally an applications developer, he brings database methodology approaches to network implementations. He combines practical experience as a thrice business owner with best practices in providing organizations with needs analysis, business logistics, IT infrastructure, and proactive maintenance. Visit SoundoffComputing.com or call (858) 569-0300. Lauren Wendler Ms. Wendler is your office manager’s SDCMS office manager advocate and can be reached at (858) 300-2782 or at LWendler@SDCMS.org. Wilma J. Wooten, MD, MPH Dr. Wooten, SDCMS and CMA member since 2006, is the public health officer for the County of San Diego, Health and Human Services Agency. She is board certified in family medicine and has a master’s degree in public health. From 1990 to 2001, she practiced medicine as a faculty member in the UCSD Department of Family and Preventive Medicine; she joined the County of San Diego in April 2001. Dr. Wooten remains a UCSD volunteer associate clinical professor and is an adjunct professor at SDSU’s Graduate School of Public Health.

Send your letters to the editor to Editor@SDCMS.org

East County Director Hillcrest Director Kearny Mesa Director EDITOR MANAGING EDITOR

Joseph Scherger, MD, MPH Kyle Lewis

La Jolla Director North County Director

editorial board

MARKETING & PRODUCTION manager Sales Director PROJECT DESIGNER COPY EDITOR

Van Cheng, MD Adam Dorin, MD Robert Peters, PhD, MD David Priver, MD Roderick Rapier, MD Joseph Scherger, MD, MPH

Jennifer Rohr Dari Pebdani Lisa Williams Adam Elder

South Bay Director At-large Director

Young Physician Director Resident physician director Retired Physician director MEDICAL Student Director

William Tseng, MD Woody Zeidman, MD Roneet Lev, MD Thomas McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steven Poceta, MD Wayne Sun, MD James Schultz, MD Douglas Fenton, MD Arthur Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD Robert Peters, PhD, MD David Priver, MD Wayne Iverson, MD Paul Kater, MD John Allen, MD Kevin Malone, MD Mihir Parikh, MD Kimberly Lovett, MD Glenn Kellogg, MD Geraldine Kang

SDCMS EXECUTIVE COMMITTEE PRESIDENT president-elect past president secretary treasurer COMM. CHAIR DELEGATION CHAIR Board REP. Board REP. LEGIslative chair executive director SDCMS cma trustees

Theodore Mazer, MD Albert Ray, MD Robert Wailes, MD

OTHER cma trustees

Catherine Moore, MD Diana Shiba, MD

ama delegates alternate delegate

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to cpinfo@sandiegomag.com. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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Stuart Cohen, MD, MPH Lisa Miller, MD Albert Ray, MD Robert Wailes, MD Susan Kaweski, MD Joseph Scherger, MD, MPH Jeffrey Leach, MD Sherry Franklin, MD Robert Peters, PhD, MD Robert Hertzka, MD Tom Gehring

James Hay, MD Robert Hertzka, MD Albert Ray, MD Lisa Miller, MD

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Editor’s Column By Joseph E. Scherger, MD, MPH

T The Secret Sauce of Office Practice Redesign Making the Process of Care Continuous Rather Than Episodic • Being Proactive With Care Rather Than Reactive • Activating Patients for Greater Self-management 6

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his issue marks the third year for devoting an issue to health information technology (HIT). Computer applications have already changed front-office procedures, and their clinical applications are spreading to change the face of medical practice. The computer with an EHR is becoming the “third person” in the exam room. Increasingly, that computer contains not just the patient’s health record but rapid access to all medical knowledge. 2009 may go down in history as the year of healthcare reform in America. If not, it certainly will be the start of major change. The current wasteful and inefficient non-systems of care are not sustainable. We need methods that are better, faster, and cheaper — the dream of any redesign engineer.

The imperative of healthcare redesign for today is to achieve a combination of cost reduction, quality improvement, and service improvement. All that is possible today with HIT applications and new methods of care. Major change has happened in most other service industries and will happen to us in medical office practice. Secure online communication with patients, even automatic communications for things like making appointments and refilling some prescriptions, is just one of the many efficiencies that HIT will bring to office practice to improve service and lower costs. Besides using Internet communications, how do we improve the quality of outcomes and improve service while lowering the cost of care? Current office practice is reactive, episodic, and physiciandependent. Our workday has us reacting to whatever is on our schedule and whatever urgencies arise. Our care is delivered episodically during office visits. As physicians, we carry the major responsibility of providing the totality of medical care to our patients. We are in charge of ensuring that our patients get all the preventive services, chronic illness care, and acute care they need. As medical knowledge grows, this responsibility becomes overwhelming. New methods of care are needed.

The imperative of healthcare redesign for today is to achieve a combination of cost reduction, quality improvement, and service improvement. Despite our best efforts, traditional office practice results in only about 25 percent of our patients getting all their recommended services or having their outcomes of chronic illness care at the target levels. It is easy for us to say that the responsibility for these gaps is on the patient. If they just came in regularly and complied with all our care, many more would be at target. While this is true, there are emerging models of care that are achieving much better outcomes.

Demonstration projects of chronic illness care have shown that working differently may result in improved quality of care at lower cost. There is a “secret sauce” of care strategies that, when combined, has a major impact on the outcomes of care to a population of patients. The three “ingredients” to this secret sauce are: making the process of care continuous rather than episodic; being proactive with care rather than reactive; and activating patients for greater self-management. While these three strategies can be done without HIT, using HIT makes them much more efficient and begins to move healthcare into modern processes much like other service industries today (banking, travel, accounting, etc.).

Despite our best efforts, traditional office practice results in only about 25 percent of our patients getting all their recommended services or having their outcomes of chronic illness care at the target levels. An online platform of communication and care services makes the access to care continuous for patients. They may log into their personal medical home anytime, have access to their medical record, and participate in whatever care services that are available. The online platform allows both sides of the care equation — the physician team and the patient — to communicate around care at any time asynchronously at mutual convenience. Once a practice has a registry of all its patients and is able to stratify patients by age, sex, preventive services, and any given disease, proactive strategies of care may follow. If you want to know how your patients with diabetes are doing, turn on the computer application and look. Rather than spending the day reacting to the patients who are on your schedule, you and your care team may embark on productive interactions with patients to improve their care. With better informa-

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tion systems, care to a population of patients may become strategic. Of course the finances must support this proactive care and reward better outcomes. That is where pay-for-performance, or, better stated, payment for results, replaces payment for just doing care. Once patients get their medical records and are linked into us as their providers of care, why not let them take a greater role in their own care? We know what preventive services we want our patients to have; why not let them obtain them directly? The experience over the past decade of studying patient self-management shows that the more the patients are involved in their own care, the better the outcomes. Conversely, the more the patients remain totally dependent on the physician to provide all the care, the worse the outcomes. The tools of HIT do not improve healthcare without the right applications. HIT is not the answer. People using HIT wisely have the potential to redesign care for the better. HIT creates new processes of care that offer the potential to greatly im-

There is a “secret sauce” of care strategies that, when combined, has a major impact on the outcomes of care to a population of patients. prove the outcomes of care. The financing of care is moving toward improved outcomes to a population of care. All physicians may begin to apply the “secret sauce” concepts to improve quality and service at lower costs. What an exciting time to be in medical practice.

the A u t ho r : Dr. Scherger, SDCMS and CMA member since 1993, is clinical professor of family medicine at UC San Diego. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

About

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SDCMS Members-only Benefits

2009

Seminars and Events

April

16 Thursday 9:00AM–1:00PM Practice Management Seminar/Webinar (Office Managers Forum) 18 Saturday 8:25AM–3:30PM Resident and New Physician Seminar: “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” 22 Wednesday 6:30PM–8:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)” 23 Thursday 11:30AM–1:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)” 29 Wednesday 11:30AM–1:00PM Medi-Cal Billing Seminar/Webinar

May 7 Thursday 9:00AM–12:30PM EMR Road Show (Office Managers Forum) 20 Wednesday 11:30AM–1:00PM Billing Seminar/Webinar (Office Managers Forum)

June 18 Thursday 11:30AM–1:00PM Legal Seminar/Webinar (Office Managers Forum)

24 Wednesday 2:00PM–6:00PM CMA Contracting Seminar/Webinar: “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations — A Focus on Payor Contracting”

25 Thursday 9:00AM–2:00PM CMA Reimbursement Seminar/ Webinar (Office Managers Forum): “Back to Basics: A Step-by-Step Guide to Maximizing Your Cash Flow”

July 22 Wednesday 6:30PM–7:30PM Risk Management Webinar: “Who Can Be Told What? (Communicating in a HIPAA World)” 23 Thursday 11:30AM–12:30PM Risk Management Webinar: “Who Can Be Told What? (Communicating in a HIPAA World)”

August 12 Wednesday 11:30AM–1:00PM OSHA Updates Seminar/Webinar (Office Managers Forum)

October 14 Wednesday 6:30PM–8:00PM Financial Issues Seminar/Webinar (Including Estate Planning) 15 Thursday 11:30AM–1:00PM Financial Issues Seminar/Webinar (Office Managers Forum)

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Free to Member Physicians and Their Office Staff! SDCMS strives to build a robust schedule of free seminars and events for our member physicians and their office staffs. All SDCMS member physicians and their office staffs attend SDCMS seminars free of charge (including Office Managers Forums). Our seminars cover a broad range of practice management topics, including legal issues, HIPAA, risk-management issues, contract negotiations, and more. For further information about any of these seminars and events, watch your emails and faxes, visit SDCMS’ website at SDCMS.org, or contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org.

Watch Previous SDCMS Seminars Online Now! Available to Members at SDCMS.org

SDCMS Member Physicians and Staff: Don’t forget that you can view all previous SDCMS seminars online whenever you like. To locate a previously held seminar for viewing, simply go to SDCMS.org and do a search in the search field on the homepage. For assistance in locating a seminar or in logging into SDCMS’ website, please contact Kyle Lewis at (858) 300-2784 or at KLewis@ SDCMS.org. All SDCMS seminars are made available for viewing online within 24 hours of their date of occurrence. Thank you for your membership!

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Community Healthcare Calendar To submit a community healthcare event for possible magazine and website publication, email KLewis@SDCMS.org. All events should be physician-focused and should take place in San Diego County.

Advances in the Neuropsychological Assesment and Treatment of School-age Children with Cognitive Deficits Presentation of the latest findings on the assessment and remediation of cognitive and behavioral impairments in school-age children. April 2–9 at the Hilton San Diego Resort. Visit http:// cme.ucsd.edu/neuro.

14th Annual Primary Care in Paradise Will assess current trends in preventive healthcare with an emphasis on endocrinology, orthopedics, obesity, migraines, COPD, melanoma, and sleep apnea; summarize recent developments and changes in the treatment of disease processes likely to be seen in the primary care office setting; and identify and treat problems commonly encountered in primary care clinical practice. April 6–9 at the Hapuna Beach Prince Hotel, Big Island, Hawaii. Contact (858) 652-5400 or med.edu@ scrippshealth.org.

Fresh Start’s Surgery Weekend A team of dedicated medical volunteers donates their time and expertise to provide disadvantaged children with the highest quality medical services and ongoing care. April 18–19, June 13–14, July 25–26, September 12–13, and November 7–8 at the Center for Surgery of Encinitas. Contact (760) 448-2021 or mimi@ freshstart.org, or visit www.freshstart.org.

2nd Annual Sudden Cardiac Arrest April 25–26 at the Hilton San Diego Resort. Visit www. scripps.org/healtheducation.

American Occupational Health Conference 2009 Topics include occupational medicine/ research, infectious disease, toxicology, workers’ compensation, ergonomics, and environmental pollution. April 26–29 at the Manchester Hyatt Hotel in San Diego. Visit www.acoem.org.

San Diego Psychiatric Society 50th Annual Installation Event and Psychiatric Symposium May 3 6:00pm-9:30pm. Contact Karen Mitrovich-Dotson at (858) 279-4586 or at KDotson@SDCMS.org.

Essential Topics In Pediatrics 2009 May 14-15 at the Catamaran Resort Hotel. Visit http://cme.ucsd.edu/events.cfm.

Integrative Holistic Nursing Conference: Bringing Healing to You and Your Patients May 15–16 at the Paradise Point Resort, San Diego. Contact (858) 652-5400 or med.edu@scrippshealth.org or visit www.scrippsintegrativemedicine.org.

2009 American Thoracic Society International Conference Educational program for clinicians and researchers in adult and pediatric pulmonary, critical care, and sleep medicine. Sample a broad spectrum of topics or concentrate on critical care, sleep, allergy/immunology, or other specialty related to respiratory medicine. May 15–20. Visit www.thoracic.org.

Alzheimer’s Disease: Update On Research, Treatment, and Care May 21–22 at the Omni San Diego Hotel. Visit http://cme.ucsd.edu/events.cfm.

Riverside County Medical Association: 5th Annual “Cruisin’ Thru CME” (Eastern Mediterranean) July 6–17. Call (800) 745-7545.

20th Annual Coronary Interventions October 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/ health-education.

XVII World Congress of Psychiatric Genetics Offers a forum for exchange of the latest scientific data and education for the interested clinician. November 4–8 at the Manchester Grand Hyatt. Contact (858) 534-3940 or ocme@ucsd.edu.

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Noted to Palmetto’s website at www.palmettogba. com/J1B and search for the article titled “Medicare Part B Medical Records: Signature Requirements, Acceptable and Unacceptable Practices.”

Ask Your

Physician Advocate By Marisol Gonzalez

Palmetto Denials • Filling Out Forms for Patients • Enrolling in Medicare

Your Physician Advocate Has the Answers!

UESTION: I have sent three appeals to Palmetto that have been denied. I also sent operative reports along with the appeals. The explanation of their decision states that there are “acceptable methods of signing records/test orders and findings.” What does this mean? ANSWER: Claims processed by Palmetto GBA on or after April 28, 2008 (for dates

of service beginning with September 3, 2007), have new signature requirements. Medicare requires the individual who ordered/provided services to be clearly identified in the medical records. The signature for each entry must be legible and should include the first and last name of the practitioner. For clarification purposes, Palmetto recommends you include your applicable credentials, e.g., PA, DO, or MD. The purpose of a rendering/treating/ ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate that the Part B services have been accurately and fully documented, reviewed, and authenticated. Furthermore, it confirms that the physician has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration. For more information on this topic, please go

UESTION: Sometimes my office staff fills out forms on our patients’ behalf. Are there any steps I should take before I start charging my patients for the completion of forms? ANSWER: Yes. You may wish to consider reviewing all managed care contracts to see whether there are any restrictions. Some contracts may only allow you to bill patients for co-pays and deductibles. This may be interpreted as a prohibition against charging for forms. Contact your payers. You may want to let them know you plan to institute a charge for form completion and avoid problems down the road. Also, notify your patients ahead of time. This will avoid surprises and hard feelings. Office staff should be briefed on exactly how to respond when patients question the need for the fees or ask whether the fee can be waived.

UESTION: I am a brand-new physician to Medicare. How do I enroll?

ANSWER: If you are new to Medicare and you are going to fill out an 855I or 855R application, you can now do this online at www.cms.hhs.gov/medicareprovidersupenroll. However, if you need to change from a solo proprietor to a solo incorporated physician, you must still do this via paper. The link above can currently only be used for new providers and reporting other practice changes.

A b o u t t h e A u t ho r : Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership.

Does Your Office Manager Have a Question Too? Lauren Wendler, your SDCMS office manager advocate, is on staff and ready to help your office manager with any questions he or she may have. Feel free to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help.

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Get in Touch

Please Welcome

SDCMS’

New and Rejoining Members Welcome New Members Raghava Rao Gollapudi, MD Internal Medicine, Cardiovascular Disease, and Interventional Cardiology San Diego (858) 244-6800

Website Snapshot

Richard Keitley Gundry, MD Internal Medicine Ramona (760) 789-8431

Address: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123

Timothy Michael Strouse II, MD Internal Medicine Chula Vista (858) 499-2707

Telephone: Dareen Nasser, office manager, at (858) 565-8888 or at DNasser@SDCMS.org Fax: (858) 569-1334

Welcome Rejoining Member

CEO/Executive Director: Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org

Stephen H. Miller, MD Plastic Surgery and Surgery San Diego (619) 543-6770

COO/CFO: James Beaubeaux at (858) 300-2788 or at Beaubeaux@SDCMS.org Director of Membership Development: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org

The Medpedia Project Medpedia.com

he Medpedia Project is a long-term, worldwide project to evolve a new model for sharing and advancing knowledge about health, medicine, and the body among medical professionals and the general public. This model is founded on providing a free, online technology platform that is collaborative, interdisciplinary, and transparent. Users of the platform include physicians, consumers, medical and scientific journals, medical schools, research institutes, medical associations, hospitals, for-profit and nonprofit organizations, expert patients, policy makers, students, nonprofessionals taking care of loved ones, individual medical profes-

Your SDCMS Support Team Is Here to Help!

sionals, scientists, etc. As Medpedia grows, it will become a repository of up-to-date, unbiased medical information, contributed and maintained by health experts around the world, and freely available to everyone. In association with Harvard Medical School, Stanford School of Medicine, Berkeley School of Public Health, University of Michigan Medical School, and other global health organizations, Medpedia will be a commons for the gathering of the information and people critical to healthcare. Version 1.0 of the online Medpedia platform was released in beta on February 17, 2009. Only physicians and PhDs are allowed to edit the articles on Medpedia after they create an account and are approved as an editor. Non-editors can create an account and then suggest changes that must be approved by an editor before going live on the site. Visit Medpedia. com for more information.

Director of membership Operations and Physician Advocate: Marisol Gonzalez at (858) 300-2783 or at MGonzalez@ SDCMS.org Office Manager Advocate: Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org Director of Engagement: Jennipher Ohmstede at (858) 3002781 or at JOhmstede@SDCMS.org sdcms foundation executive director: Kitty Bailey at (858) 300-2780or at KBailey@SDCMS.org sdcms foundation associate executive director: Tana Lorah at (858) 300-2779 or at TLorah@SDCMS.org Director of Communications and Marketing: Kyle Lewis at (858) 300-2784 or at KLewis@ SDCMS.org Specialty society advocate: Karen Dotsonat (858) 300-2787 or at KDotson@SDCMS.org Letters to the Editor: Editor@SDCMS.org General Suggestions: SuggestionBox@SDCMS.org

Note: Text Taken From the Medpedia Website

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Noted

CMA Advises MDs to Begin EHR Needs Assessment Process Now Physicians: Get Noticed! Wish Your Legislators a Happy Birthday! Let your legislators know that you’re watching and that you vote — send them a birthday card this month! Congresswoman Susan Davis 4305 University Ave., Ste. 515 San Diego, CA 92105 Telephone: (619) 280-5353 Fax: (619) 280-5311 Email (via website): http://www.house.gov/ susandavis/contact.shtml Birthday: April 13

Visit CMA’s HIT Resource Center at CMANet.org/HIT

he 2009 federal economic stimulus package includes $19 billion for health information technology (HIT), the vast majority of which will be directed to physicians to subsidize the purchase and usage of electronic health record (EHR) systems. Beginning in 2011, qualifying Medicare providers stand to gain up to $44,000 under the program; qualifying Medi-Cal providers stand to receive as much as $64,000. Many of the standards governing the subsidies will be worked out in the coming months. Given the lack of clarity about what EHR systems will qualify a physician to receive the federal subsidy, CMA believes that now is not the time to rush out and purchase a system. In the meantime, CMA advises physicians to begin the pro-

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cess of assessing their EHR needs, with an eye on what will work best for their specialties, the sizes of their practices, their career stages, and their comfort levels with technology. Because of the complexity and cost involved with selecting and implementing an EHR, it is imperative that physician practices plan accordingly. To help, CMA has created an HIT Resource Center — CMANet.org/HIT — where you will find the latest information, answers to frequently asked questions, and links to HITrelated resources for physicians. CMA is closely monitoring the HIT standards development process and will be updating the resource center as new information becomes available.

Merchant Services: Credit/Debit Card Processing Potential Value: $1,500 for high-dollar, high-volume cost! Chase Paymentech provides member physicians fast, secure, and cheaper credit card payment processing, excellent customer service, and innovative payment options. SDCMS members receive upgraded customer service, free online reporting, and a guaranteed 10–20 percent savings from current costs. Let Chase Paymentech provide you with a competitive quote today by sending three months of merchant statements to Janet Lockett at JLockett@SDCMS.org, by fax to (858) 569-1334, or call her at (858) 300-2778. Technology Solutions Potential Value: $1,000! Soundoff Computing Corporation provides bestof-breed hardware, software, and network technologies for your medical practice, utilizing best practices for all aspects of IT implementations. SDCMS member physicians receive free site inspection and subsequent infrastructure recommendations; free inventory and assessment of network and hardware computing assets; free analysis of Internet/telco/ data activity and subsequent ROI recommendations.To learn more, visit www.soundoffcomputing. com or contact Ofer Shimrat at (858) 569-0300 or at ofer@ soundoffcomputing.com. Banking Products and Services Potential Value: $2,500! Torrey Pines Bank is a “lowmaintenance” bank that meets business owners’ high expectations while requiring of them the absolute minimum of time and effort. Approved SDCMS members receive no-fee lines of credit, $1,000 fee discounts on commercial real estate loans, waived monthly maintenance fees on personal accounts for practice partners and employees up to $10 per month, free first order of standard checks for personal accounts, increased deposit interest rates, waived monthly maintenance fee for business online banking and bill pay services, ATM fees waived up to $15 per month, and free courier service or remote deposit service. Contact Benjamin Pimentel at (858) 259-5317 or at bpimentel@ torreypinesbank.com. Insurance Products and Services Potential Value: $1,000–$2,500! Alliant Insurance Services, Inc., is California’s largest premier specialty insurance broker and ranks among the 13 largest in the

nation. SDCMS members receive discounts on a comprehensive portfolio of insurance products and services, including savings of 5–10 percent or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12 percent on long-term disability income protection, and no-cost human resources consulting. Contact Mark Allan at (800) 654-4609 or at mallan@ alliantinsurance.com. Visit Alliant Insurance Services online at www. alliantinsurance.com. Tamper-resistant Prescription Pads Potential Value: $300! American Security Rx, which is a California Department of Justice and California Board of Pharmacy approved Security Printer (SP-9), provides tamperresistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamperresistant prescription forms. Contact American Security Rx at (877) 290-4262 or at info@ americansecurityrx.com. Visit American Security Rx online at www.americansecurityrx.com. Billing Solutions Potential Value: $1,000! CHMB Solutions provides outsourced medical billing, revenue cycle management services, information technology support, and hardware solutions to physician practices, clinics, and multi-specialty organizations. SDCMS members receive a 50 percent discount on startup fees and a $33 per-physician-permonth services credit, 10 percent off of outsourced IT support, 10 percent off of already discounted Dell hardware solutions, and a free coding hotline. Contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com. Email your coding question(s) to SDCMS at Coding@SDCMS.org. Visit CHMB Solutions online at www.chmbsolutions.com. Contract Analysis Potential Value: 10 percent of Net Revenue! Coastal Healthcare Consulting Group, Inc., is a specialty consulting firm that assists clients with managed care contracting, contract negotiations, credentialing, revenue enhancement, and strategic planning. SDCMS members receive a free contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts! Contact Kim Fenton, president, at (949) 481-9066 or at kimf@healthcareconsultant.

org. Visit Coastal Healthcare Consulting Group online at www. healthcareconsultant.org. For consultation scheduling, contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@ SDCMS.org. Practice Management Consulting Potential Value: $1,000–$2,500! Practice Performance Group (PPG) provides high-performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and

and a 7.5 percent dividend credit. To learn more, contact Janet Lockett at SDCMS at (858) 3002778 or at JLockett@SDCMS. org. Visit TDC online at www. thedoctors.com. Collections Services Potential Value: $350–500! TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992. This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field. SDCMS members receive a 10 percent discount on monthly charges. Contact Catherine Sherman at (888) 687-

SDCMS

Endorsed Partner Benefits

Total Potential Value to SDCMS Members:

$10,000–$17,000 management, market strategy and tactics, practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense. PPG also conducts free half-day seminars for SDCMS members and their staffs at SDCMS’ offices. Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com. Visit PPG at www.PPGConsulting.com. Professional Liability Insurance Potential Value: $500–$2,500! The Doctors Company (TDC) enjoys a reputation as the industry vanguard for low California rates, aggressive claims defense, expert patient safety programs, superior customer service, and exemplary member benefits. Most SDCMS members are eligible for a 5 percent discount on insurance premiums A p r i l

4240, ext. 14, or at csherman@ tscarsolutions.com. Visit TSC online at www.tscarsolutions.com. Accounting Services Potential Value: $500–$2,000! AKT CPAs and business consulting LLP has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. SDCMS members receive a 15 percent discount on standard rates for professional services, with an unconditional satisfaction guarantee: “SDCMS members who are not completely satisfied with the work AKT performs for them pay only what they thought the work was worth.” Contact Ron Mitchell at (760) 268-0212 or at rmitchell@ aktcpa.com. Visit AKT at www. aktcpa.com.

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SDCMS Membership

Candidate Statements

For SDCMS Board of Directors and AMA Delegates President: Lisa Miller, MD I am honored to assume the position of president of the San Diego County Medical Society (SDCMS). I look forward to the challenges ahead, for medicine, for the delivery of healthcare, and for SDCMS member physicians. SDCMS needs to continue to have a strong voice in legislative issues locally, statewide, and nationally. As physicians, we are faced with ever-increasing challenges to our autonomy to practice medicine, to deliver timely and appropriate care to all members of our community, and to be reimbursed appropriately. As a medical society, we must maintain a strong membership base and continue to provide our physicians with valued benefits. I look forward to the privilege of serving the San Diego County physician community. Notes: Number in parentheses after name (X) = term length in years. Asterisk after name (*) = incumbent.

Candidate for SDCMS President-elect (unopposed): Susan Kaweski, MD (1)

I am honored to be your candidate for presidentelect. I have served as your Kearny Mesa board of directors representative, delegate to the CMA House of Delegates, chairman of the Legislative Committee, member of the Finance Committee, secretary, and most recently as treasurer. During these tough economic times, President Obama wants to provide affordable, accessible healthcare for all Americans. We have to be at the negotiating table as the decisions are being rendered, or other healthcare providers will step up to provide cheap care, which, in the long range, becomes very costly for the patient when diagnoses are missed. In addition, we cannot afford to lose appropriate payment due to grossly unfair Medicare RBRVS GPCI disparities with San Diego County included in a rural payment area. Healthcare plans are increasingly controlling our practices. We have to waste time and energy on filling out forms and calling them about nonpayments in return for nominal retribution. It is time we get paid fairly for

our services, especially when we render emergency care outside our contracted plans. Health information technology will be required of all physicians. The Obama administration has said that the goal of HIT is to “reduce costs and guide your doctor’s decisions.” If you do not become a “meaningful user,” you will face penalties. Don’t let our autonomy be lost! The trial attorneys are always challenging MICRA. We are so fortunate in California that our malpractice rates are among the lowest in the country, but we need to continually be vigilant that this will not be taken away because our lawmakers view this as outdated legislation. These difficult times require strong organization. It is your SDCMS and CMA that provide the necessary ammunition to meet these challenges and defend your rights. I look forward to joining you in this mission as your president-elect.

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Candidate for SDCMS Treasurer (unopposed): Robert Wailes, MD (1)

These are very tough times for just about everybody. Patients lack good access

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to care, doctors’ practices are suffering from too much overhead, and the economy stinks! I think we can all agree that governmental overregulation and insurance company bullying are affecting our professional quality of life. We all have a lot to complain about, and I think organized medicine is the best way to look for solutions. One unified voice has the best chance of successful lobbying for our patients’ health and our professional careers. I have really enjoyed working with SDCMS at the local and state levels as an advocate representing the North County medical community. I would like to bring this experience, enthusiasm, and optimism for progress forward to be treasurer for the San Diego County Medical Society. I appreciate your support as well as any input you may have to offer. I am a firm believer that the more involvement and brainpower we can recruit, the more our organization and community as a whole will benefit. Candidate for SDCMS Secretary (unopposed): Sherry L. Franklin, MD (1)

We are at the forefront of a significant time of change in the practice of medicine. It is now the time to be sure our voices are heard, our hearts are felt, our profession is preserved, and our patients are protected. Partisan politics and the fear of not being re-elected dictate policy driving medicine today. My hope is to echo the words of Dr. Hertzka in saying that physicians are here to be part of the solution, and add my own words that we are here to be part of it on a grand scale. We must sit at the table. We must be willing and able to negotiate. We must have the best interest of our practice and our patients at the forefront of our decisions. I would like all of you to know that I am the candidate who is ready, willing, and able to sit at that table. I will fight tirelessly for your rights, regardless of specialty. Candidate for SDCMS Kearny Mesa Geographic Director #2 (unopposed): John Lane, MD (2)

Thank you for considering me for the position of director on the SDCMS board. I have been practicing orthopedic surgery in San Diego since 1990. Through my fellowship in sports medicine and private practice, I have had the opportunity to practice in HMO, solo and small group, as well as large group settings. This has allowed me to

be in practice settings that have treated managed care, private practice, and workers’ compensation patients. I believe that these experiences give me a broad perspective regarding the practice of medicine in our community. As a physician who takes trauma call, I find emergency room coverage, balance billing, and patient access to be issues that need physician input to provide realistic solutions. I would be grateful for the opportunity to bring my experience to the SDCMS board to help our member physicians maintain successful practices and provide high-quality care to patients as we navigate these changing times. Candidate for SDCMS East County Geographic Director #2 (unopposed): Heywood “Woody” Zeidman, MD* (3)

I have been privileged to represent the San Diego County Medical Society (SDCMS) at CMA since 1992. Starting as an alternate, I was honored to become a full delegate. I have since become the representative for East County on the SDCMS board of directors. However, SDCMS rightly has term limits to allow for increased involvement of its members. This is the last time I can run as the district representative to the board. I have authored resolutions, on your behalf, accepted as policy by CMA. I have been a representative to special sections of both CMA and AMA. Please allow me the honor to represent the East County district one last time. Candidate for SDCMS La Jolla Geographic Director #1 (unopposed): Steven Poceta, MD* (3)

I hope to remain a member of the San Diego County Medical Society board of directors and delegate to the California Medical Association. I have been an elected board member representing La Jolla since 2004. I have been practicing at Scripps Clinic since 1988 and have been a member of SDCMS and CMA since that time. I am committed to the fair and open representation of our profession to the financial and political systems in which we operate. I have tried, since 2004, to bring the voice of La Jolla physicians to the board and to the state. I have participated in various training programs to help me do this in a competent manner, attended various political events such as fund-raisers, and kept up with issues of healthcare reform. Physicians from my district come from many types of practices. I am a member of Scripps Clinic Medical Group, a large multi-

specialty group, where I have served on the board of directors and been active in a number of committees. Although a large group practicing on contract with a foundation, Scripps Clinic represents a mix of different practice styles. We are not paid on salary, but on productivity. Much of each of our successes comes from individual relationships with referring physicians, not from large HMO contracts. Because of this, I understand some of the problems and issues that physicians face in small and solo practice. Scripps Clinic also has an academic model of practice where research and teaching in our residency program and fellowship programs are encouraged. In this regard, Scripps Clinic operates as an academic model, pooling revenue prior to distribution. We have practiced capitated medicine as a major model (and still have a small number of such contracts). I understand some of the primary care/specialist differences. Lastly, as we have grown larger, we initiate physician benefits such as retirement plans, reminding me of several of our physicians who have left to work at Kaiser for just such benefits. I recognize the differences that physicians have on some of these issues, especially electronic medical records and pay-for-performance. I hope to continue to bring these background perspectives to the upcoming issues facing medicine in the coming few years. I support current CMA and AMA policy guidelines on healthcare reform, whatever the ultimate form this takes. Basic principles include an individual mandate, regulation of any private insurance element to enforce community-rating mechanisms, a government safety net, and physician autonomy from regulation and employment by government or hospital where feasible. I personally think that a government-sponsored universal healthcare system is not practical or desirable. However, if our society decides that this is the best way to make our country’s health strong, I will fight within that system for adequate physician autonomy, the relationship with the patient, adequate reimbursement, and freedom from burdensome regulation. Should we choose to strengthen and enhance our system of employee-based healthcare insurance, we need to improve regulation on the insurance industry and devise a mechanism for universal coverage or near-universal coverage. Lastly, we need to stop the upcoming Medicare cuts and reform the GPCI system to ensure stability — and do it this year. Please support my candidacy for SDCMS directorship.

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Candidate for SDCMS North County Geographic Director #1 (unopposed): James Schultz, MD* (3)

Thank you for your consideration for membership on the SDCMS board. I have been a family medicine specialist in Escondido since 1988. I have a broad range of clinical and administrative experience, and continue to be active clinically in the outpatient setting and in the inpatient setting as a part-time hospitalist at Palomar. I have had the honor to serve in various administrative roles as well, including as medical director of a larger private practice group and currently as the CMO for a group of Community Health Centers. I will, if elected, bring a unique perspective to the board, that of a frontline physician in the safety-net world who has also lived the leading (bleeding) edge of managed care. The Community Health Centers take care of hundreds of thousands of patients and deal with resource limitations and scarcity of available services on a daily basis. We and our patients are among those most at the mercy of the whims of local, state, and federal policy, yet traditionally have not been represented in SDCMS. Candidate for SDCMS North County Geographic Director #2 (unopposed): Arthur “Tony” Blain, MD, MBA* (3)

It is a privilege and an honor to be a candidate for reelection to the position of SDCMS North County director. I am a family practice physician and faculty at the Naval Hospital Camp Pendleton Family Practice Residency. In both my current position on the board of directors for SDCMS and, when I was a resident, as president of the California Medical Association Residents and Fellows Section, I have had the opportunity to see firsthand the challenges facing medicine regionally and nationally, such as medical coverage for the uninsured, malpractice reform, reimbursement, access to care, and healthcare reform. The only way to protect and improve our profession is for physicians to serve in political, leadership, and organized medicine roles. I feel a deep debt of gratitude for those who have served in organized medicine before me, and serving as an SDCMS director is my way to contribute in a proactive way to support and improve our profession. Candidate for SDCMS East County Geographic Alternate Director (unopposed): Venu Prabaker, MD* (3)

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Candidate for SDCMS Hillcrest Geographic Alternate Director (unopposed): Eric Yu, MD* (3)

Candidate for SDCMS North County Geographic Alternate Director (unopposed): Steven Green, MD* (3)

I am honored to be a candidate for SDCMS North County alternate director. I am a family physician, practicing with Sharp Rees-Stealy Medical Group in Mira Mesa for the past 20 years. I’ve participated in the CMA House of Delegates through the specialty delegation for the last several years. Given the difficult economic times we find ourselves in, it is more important than ever for San Diego County physicians to focus on our common ground and work together. Government is taking a more active role in areas like universal healthcare access, and nonparticipation in any such effort is not really an option. Candidate for SDCMS La Jolla Geographic Alternate Director (unopposed): Matt Hom, MD (2)

U.S. medicine is at a crossroads. With healthcare reform at the front of the president’s agenda, I feel that physician participation in the process will be critical to ensuring that physicians are properly represented moving forward. As an internist in private practice caring for patients on several outpatient and inpatient levels, my experience provides me a breadth and perspective on the dynamics and issues that confront medicine today. Candidate for SDCMS At-large Director #2 (unopposed): Robert Peters, MD, PhD* (3)

I have had the privilege to represent physicians of San Diego County for the last three years. During this time I have been a delegate to the CMA House of Delegates, chaired Reference Committee E on Quality, Ethics, and Legal Affairs, and serve on CMA’s Council on Ethical and Legal Affairs. Currently, I am your board of directors representative to the SDCMS Executive Committee. I want to continue my active involvement in organized medicine and seek your support for reelection. The San Diego County Medical Society has a rich his-

tory as a leader in both local and state issues. More than ever these issues will have a profound impact on the quality of your practice and that of your patients’ lives. These issues include the protection of MICRA, scope of practice, reimbursement, access to and quality of care, information technologies, and satisfaction of practicing medicine. If reelected, I will proudly serve as your advocate, solicit your input, and seek solutions to the issues that are germane to your mode of practice. Candidates for SDCMS At-large Director #4: David E.J. Bazzo, MD (3)

I seek the privilege to represent San Diego County physicians as an at-large director for the San Diego County Medical Society. I have a long history of serving our profession and acting as a physician advocate. I am currently a clinical professor in the Department of Family and Preventive Medicine at the UCSD School of Medicine. One might ask whether an academic physician could represent the community of physicians of San Diego County. I will let my past record speak to this. I have served on the board of directors for the San Diego Academy of Family Physicians since 2001, serving as president in 2005. During my time on the board, I have been fortunate to be involved in planning educational opportunities for our membership, and to be involved at the local and state levels in physician advocacy and support. I have been selected as one of San Diego’s “Top Doctors” for the past four years by my colleagues. This year is a particularly important year for healthcare. As the new administration has made healthcare one of its top priorities and our state budget issues have forced a hard examination of delivery of healthcare and its funding, having a voice on how the future is shaped is paramount. Nathan Fletcher, our 75th district assemblyman, is the vice chair of the California Assembly Committee on Health. Advocacy for the San Diego County physician will take on extra importance. We need someone who will work for physicians, and I vow to commit tirelessly to this service. I seek your support in electing me as at-large director #4.

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Wayne Iverson, MD* (3)

I appreciate the opportunity to serve the medical community and bring an extensive background and experience in my medical professional activities. I am a physician in private prac-

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tice with offices in La Jolla and Poway. I am a clinical professor of medicine at UCSD, volunteer faculty, and a fellow of the American College of Physicians. I served as chairman of the Graduate Medical Education Committee at Scripps Memorial Hospital La Jolla. Also, I served on a CMA task force charged with acquiring a completely new enterprise database and association management system for CMA. Previously, I was appointed as a Solo and Small Group Practice CMA delegate from San Diego County. At the 2006 CMA House of Delegates meeting, I authored and successfully pushed through a late emergency resolution calling on CMA to undertake a national campaign for Medicare reform. As an SDCMS director, I will endeavor to maintain our professional traditions related to patient care, educating new physicians, and serving the community. The changing social environment, economics, medical technology, and computer technology will touch on every aspect of medical care. With your support, I am confident I can be a positive factor integrating these changes into our medical professional culture and at the same time maintaining our traditions as physicians. Candidate for SDCMS At-large Alternate Director #3 (unopposed): Ben Medina, MD* (3)

Candidate for SDCMS At-large Director #7 (unopposed): Mihir Parikh, MD (2)

It is a privilege and an honor to be a candidate for the position of “at-large director” for SDCMS. I thoroughly enjoyed learning and participating in the political process as a “young physician director” over the past three years. During this time I have come to understand the importance and necessity of having an active medical society that bridges multiple specialties and multiple types of physicians. The consensus voice that emerges from SDCMS becomes our position when discussing issues such as access to healthcare, scope of practice, and quality of patient care. This voice is very important in the coming years as healthcare reform gets under way. I am very interested in continuing to participate in the process of representing physicians at SDCMS meetings, helping to formulate organized medicine’s position, and then communicating this information back to the physicians and, of course, the

public. If elected, I will do this to the best of my ability. Candidate for SDCMS At-large Alternate Director #6 (unopposed): Alan Schoengold, MD (2)

I appreciate the opportunity to serve as an at-large alternate director for SDCMS. I have been a member of SDCMS for 35 years, and I’ve had the privilege of serving on the boards of a few IPAs in the past 20 years. As the president of Sharp Community Medical Group for the past four years, I have had extensive exposure to the ongoing development of managed care in San Diego County. I believe the SDCMS board will benefit from the experience I will bring to our local and state medical societies. I look forward to working with my colleagues on the board of directors to strengthen the relationships between our medical leaders in San Diego County. Candidate for SDCMS Young Physician Director (unopposed): Kimberly Lovett, MD (1)

I am enthusiastic to represent the voice of the young physician on the board of the San Diego County Medical Society. I have had the opportunity to work closely with and learn from many of the board members and staff at SDCMS over the past two years. SDCMS and CMA have been instrumental in developing ideas and providing education to patients and nonmedical professionals in the arenas of healthcare reform and access to care. I have a passion for actively participating in the transformation of our system of medicine, and I believe it can be done through a collective effort among physicians within organized medicine. I pledge to represent the interests of young physicians who will inherit the changes that are occurring today as new legislation is passed at the city, state, and national levels. I pledge to take an active role in ensuring that the occupation we love only grows stronger and more functional for ourselves and our patients. Candidate for AMA Delegate (unopposed): James T. Hay, MD

I have had the privilege of serving you in many capacities over the past 24 years, including as the 2001 president of SDCMS; the first president of the SDCMS Foundation; delegate, trustee,

and now speaker of the CMA House of Delegates; and delegate of Our AMA. I hope and expect to become the next CMA president from San Diego County in 2011. More important than the titles we accumulate are the accomplishments of your San Diego County AMA team. The Hertzka, Hay, Ray, and Miller team is a major influence within our California delegation to AMA. This past fall, I wrote and introduced a series of resolutions that resulted in the adoption by the AMA HOD of the “Principles of the Patient-centered Medical Home.” I was part of the campaign to elect Bob Hertzka to AMA’s Council on Medical Services. I am chair of the Finance Committee of the delegation and helped to reduce expenses for CMA during these tight budgetary times. I have become a recognized consensus-building voice in the AMA House. Locally, I am proud of the tremendous growth of SDCMS since we hired CEO Tom Gehring in 2001; of the Foundation, now an important part of the charitable community in San Diego County; of what the Foundation’s Project Access will do for the underserved; and of the reorganized governance structure of SDCMS, begun during my presidential year, that, along with a dynamic CEO and current leadership, has made San Diego County the premier county medical society in California. We need leaders who build consensus and can get things done. Certainly, as we face the challenges of healthcare reform and system reorganization proposals of the new administration in Washington, DC, we want people who understand the policy and the politics. I am very grateful that you have believed that I do, and I ask for your support to continue as your delegate to the AMA House of Delegates. Candidates for AMA Delegate: Robert E. Hertzka, MD

In these most challenging of times, I have become the first San Diego County physician in decades to actually reach the senior policymaking ranks of AMA. Last year I was elected unanimously by the 475 delegates of AMA to be one of only nine physicians on their Council on Medical Service. This Council is charged with developing virtually all of the socioeconomic policy for AMA, and I am now there to represent the interests of San Diego County’s physicians. Times have never been more challenging for us. While headline after headline high-

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lights the nation’s escalating economic woes, physicians have been economically pounded for decades. We have had to deal with underfunded Medicare and Medicaid programs, unfunded mandates on our cost of practice, and private health insurers who have been so abusive in their practices that they were successfully sued as racketeers just a few years ago. Against these challenges, I have been honored to aggressively represent the physicians of San Diego County in various capacities for nearly 20 years, including as your SDCMS president in 1999 and your CMA president in 2004–05. And I continue to be fully engaged at the local, state, and federal levels — all while maintaining a full-time practice and teaching two health policy courses at the UCSD School of Medicine. Finally, I would note that on the federal level, in addition to my active participation on your behalf in AMA affairs, I continue to travel to Washington, DC, several times each year to stay in touch with many in Congress, including our five local representatives. And, as recently as last summer, I spent two hours on the phone one morning to convince wavering members of Congress to support reversal of a pending Medicare physician payment cut — just as the vote was about to be taken. I respectfully ask for your support to be reelected as one of your AMA delegates. Wayne Iverson, MD, MBA

As a medical student at Northwestern University School of Medicine, I gained my academic training several blocks from the home offices of the American Medical Association in Chicago. My professors were not only giants in academic medicine but critically involved in AMA activities. It was at this early age in my adult life that I gained undying respect for my fellow physicians and their ability to work collectively to advance the medical profession in all its activities. I never had any doubts that my life as a physician would have the three integral parts of clinical patient care, teaching young physicians, and serving my colleagues in our professional associations. I first became a member of AMA in 1978 and believe I have a great deal to offer as an AMA delegate. It is a privilege to have my name placed in consideration for AMA delegate, and I would be honored to receive your support.

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Bioethics By Lynette Cederquist, MD

You and your patients can download the POLST form free of charge at FinalChoices.org.

Physician Orders for Life-sustaining Treatment Now Available in California

hile methods of documenting end-of-life wishes have included advance directives, preferred intensity of care, and living wills, an improved option is now available in California. Physician Orders for Life-sustaining Treatment (POLST) is a physician order form that complements an advance directive by taking the individual’s wishes

regarding life-sustaining treatment and converting them into a medical order. POLST is designed both to be a statewide mechanism for an individual to communicate his or her wishes about a range of lifesustaining or resuscitative measures and a portable, authoritative, and immediately actionable physician order that will be honored across treatment settings.

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POLST is particularly useful for persons who are frail and elderly or who have a compromised medical condition, a prognosis of one year of life or less, and/or a terminal illness. It should be executed as part of the healthcare planning process and reflect careful decision making by the person and/or their legally recognized healthcare decision maker, in consultation with their physician, about the patient’s specific condition. While the POLST form can be explained to the patient or his or her representative by a healthcare provider such as a licensed nurse or social worker, questions about the efficacy or appropriateness of the treatment options should be deferred to a

POLST is particularly useful for persons who are frail and elderly or who have a compromised medical condition, a prognosis of one year of life or less, and/or a terminal illness.

San Diego County’s

POLST Implementation Project

Lynette Cederquist, MD, co-chair of the San Diego County Medical Society’s Bioethics Commission, has received a two-year grant to head up San Diego County’s POLST Implementation Project. Under this project, several trainers will be educating appropriate professionals within the community, including hospital staffs, senior living facilities, hospices, and EMS professionals on the proper use of the POLST document. If you would like more information, have questions, or would like training at your facility, please contact the project coordinator, Karen Mitrovich-Dotson, SDCMS specialty society advocate, at KDotson@SDCMS.org or at (858) 300-2787. The 2009 California POLST form is also available for download free of charge at FinalChoices.org.

discussion with his or her physician. One of the many goals of the POLST form is to increase the number of patients who have informed conversations with their physicians about their end-oflife preferences, which can be written as a physician’s order and placed in the patient’s medical record, thereby increasing accessibility to the patient’s goals by medical staff. As identified in the 2004 RAND review of the evidence-based literature published between 1990 and 2007 regarding the effectiveness of interventions is the fact that when using POLST, which is “designed to travel across treatment settings to ensure continuity of care, orders regarding CPR in nursing homes were universally followed and were honored across settings. Residents with a POLST received more comfort care and were rarely transferred to a hospital for life-sustaining treatment.”

the A u t ho r : Dr. Cederquist, SDCMS and CMA member since 2005, co-chairs the SDCMS Bioethics Commission.

About

Do You Know of Any Physician Volunteer Opportunities? A p r i l

If you know of any volunteer opportunities for physicians in San Diego County, California, across the United States, or anywhere else in the world, please email the information to Editor@SDCMS.org. SDCMS will publish all physician volunteer opportunities free of charge on our website at SDCMS.org.

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Interview By San Diego Physician

Natalie Germuska, RN, MSN CEO, Kindred Hospital

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Note: This interview is one of an ongoing series of interviews with San Diego County hospital leaders conducted by San Diego Physician magazine. Neither San Diego Physician magazine nor the San Diego County Medical Society (SDCMS) supports or opposes any views expressed by an individual interviewed for the purposes of publication in San Diego Physician magazine. [The following interview was conducted on February 5, 2009. Visit SDCMS.org to read the complete interview transcript.]

San Diego Physician: It looks as if you’re celebrating your 15th anniversary. Is Kindred a young hospital? Natalie Germuska: Actually, Kindred has been around for a long time. We’re the only Kindred Hospital in San Diego, but we’re part of the Southern California District, which is eight hospitals, and there are 82 long-term acute care (LTAC) hospitals nationwide.

SDP: How many patients, staff, physicians do you have here? Germuska: Two hundred staff, that’s roughly what we’re running right now, and about 100 physicians on staff — it’s mostly internal medicine, pulmonary coverage, but I do have ENT, plastic surgery, vascular surgery, general surgery, anesthesia. For a small hospital we actually have all the specialties on board right now, and that was something that has evolved over the last three years. To actually build our census, in talking with the community, short-term acute care facilities, and physicians, we realized that we needed to provide the gamut of services. By having specialists on staff we are able to provide a higher level of care than the sub-acute setting and expand the types of patients we admit. I believe that specialist coverage has been problematic with long-term acute cares because we’re small; physicians don’t want to extend their practice to us. So it’s really important to get out to the community and show our outcomes, what we can actually do for patients, and pulling those types of physicians in to help us care for them. We’ve been very successful with that.

SDP: How many patients? Germuska: We run a census in the 50s, and we have 70 licensed beds, 68 operational. We are busier in the winter months as this is when the cold and flu season hits and there are many more medically complex patients requiring prolonged weaning

from mechanical ventilation. At any given time, 50 percent of our census is patients weaning from a ventilator. We also have many patients with infections, so a lot of them need to be in private rooms. About half our rooms are private, the others are semi-private, which sometimes limits admission capability. We would like to increase our census to 60 on a consistent basis.

SDP: Do you contract with one medical group? Germuska: No, we’re a melting pot. Our medical director is a Sharp physician; he’s a triple-boarded pulmonologist, Dr. Davies Wong, from the Sharp Chest Medicine Group. And then we have Dr. Sam Clark, again triple-board-certified in internal medicine, critical care and pulmonary medicine, who oversees our Critical Care Unit and Night Physician Program, and he’s actually a Sharp and Scripps physician. We also have physicians with primary practices at Scripps Mercy, Paradise Valley Hospital, Alvarado, and Grossmont on staff. They all consult and cover for each other. We are the great melting pot of San Diego. They share ideas and we are able to take best practices from the San Diego area and incorporate them into protocols and daily practice. Our ventilator-weaning protocols were influenced by pulmonologists from Scripps, Sharp, Alvarado, and UCSD. So we have the best of all minds working on care initiatives at Kindred. I believe our positive patient outcomes speak to these initiatives.

SDP: How do you get the word out about what you do? Germuska: The way that we educate the community and the physicians about the services that we have is through oneon-one meetings and group presentations. We have a team of clinical liaisons; they have different clinical backgrounds, either nurses or respiratory therapists, and myself, we go out and promote our services. We’re active in the Chamber of Commerce, a member of the Better Business Bureau, active in our community, lung and heart as-

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sociations, and nursing groups. Educating nurses is one way that we can gain access to physicians and influence referrals of patients. We meet with medical directors of physician organizations, managed-care payers, and the hospitals. Those folks talk with their colleagues and link us to physicians who may have patients appropriate for this level of care.

SDP: Tell our readers about the services that you provide and how they can access those services. Overall, we offer a full range of clinical services for the medically complex patient, including intensive care, rehabilitation, and telemetry/cardiac monitoring. We have interdisciplinary team rounds and weekly care conferences that families attend so they are updated on the plan of care for their loved ones — they feel more involved. As I mentioned earlier, we have accessibility to many specialists and two licensed operating rooms, digital radiology services, and floro capability. We’re getting a new multi-site CT scanner onsite in April. There are a lot of great things that are happening here, a lot of growth, and I want people to know that about Kindred. All a physician needs to do is give us a call if they want to know more. We’ll link them to our director of marketing, one of our clinical liaisons, or myself. We’ll come to the physician, case manager offices, give them the information they want, and give them a quick overview of our outcomes. If they ever have a question about a patient, they can just call the main number or one of our liaisons directly, and we’ll go out and evaluate their patient and let them know if they meet the criteria.

SDP: What’s the main number? Germuska: It’s (619) 543-4500, and our admissions office is extension 4265. Gene Calvert, our admissions coordinator, will contact whomever is appropriate for patient evaluation. After hours, our hospital operator will direct the referral to the clinical liaison on call. We are available 24/7.

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County Public Health Officer’s Update By Wilma J. Wooten, MD, MPH

Place Matters to Your Patients’ Health

Neighborhood Design and Community Resources

here one lives can affect health, positively or negatively. Beyond the traditional numbers associated with health, such as blood sugar and weight, it is well documented that an individual’s address, ZIP code, and census tract can greatly impact health equity. An individual’s physical activity level, eating habits, and other health behaviors are impacted by the design of their neighborhood and their access to community resources, such as transportation, parks, recreational facilities, and healthy food outlets. As physicians, you may make recommendations to your patients to eat healthy and exercise, but does their environment support these recommendations? Do they have access to buying healthy foods or a safe place for recreation? The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR) working group describe the “social determinants of health” as factors in the social environment that contribute to or detract from the health of individuals and communities. These factors include, but are not limited to, socioeconomic status (e.g.,

education, employment status, income), transportation, housing, access to services, discrimination by social grouping (e.g., race, gender, class), and social or environmental stressors. Recent studies show differences in the medical treatment and outcomes of different racial and ethnic groups. These differences persist even when comparing patients of the same gender, condition, age, income, and insurance. Those with a higher income have better health outcomes compared to poorer citizens. Striking health disparities or health inequities are associated with higher rates of cancer, infant mortality, diabetes, and asthma, to name a few. For example, in San Diego County the adjusted rates per 100,000 people for diabetes hospitalization in 2007 are 346 for black, 235 for Hispanic, and 100 for white. In comparison, the adjusted rates for asthma hospitalizations in 2007 were 217 for black, 68 for Hispanic, and 54 for white. In its Healthy People 2010, the CDC offers two broad health goals for the nation: increasing the quality and years of healthy life, and eliminating health disparities/inequities. There is also the global movement

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sponsored by the World Health Organization (WHO) to address health inequity. In 2005, WHO established the Commission on Social Determinants of Health to review data and develop programs and policies to achieve health equity through impacting the social determinants of health for the world’s citizens. Locally, the County Health and Human Services Agency (HHSA) and community partners work together to address many issues of inequities by focusing efforts on environmental and policy changes. In December 2008, Public Health Services sponsored the “Unnatural Causes: Place Matters” forum based on the Public Broadcasting Service (PBS) series that described the unequal distribution of social, economic, and environmental conditions that impact health, and how communities can come together to find a solution for these “unnatural causes.” The “Place Matters” segment identified examples of how where a person lives can potentially affect their health, depending on the surrounding physical, economic, social, and service environmental factors. For more information on this compelling series, visit UnnaturalCauses.org.

The San Diego County Childhood Obesity Initiative (COI), a countywide public/ private partnership collaboration, was designed to engage community partners to implement the strategies outlined in the Call to Action: San Diego County Childhood Obesity Action Plan. County supervisors Pam Slater-Price and Ron Roberts provided leadership in the creation of the Obesity Action Plan and the ongoing efforts to work collaboratively with community partners to address this issue. To access the plan, visit OurCommunityOurKids.org. This comprehensive plan emphasizes policy and systems changes that will positively impact the health of San Diego County children (and their families). The Action Plan identifies seven domains where efforts can have the most influence in shaping healthful environments: governments; healthcare systems and providers; schools, before- and after-school providers; childcare and preschool providers; community-based, faith-based, and youth organizations; media outlets and the marketing industry; and the business domains. To learn more about these domains, visit OurCommunityOurKids.org. Through the COI “government” domain, community leaders and key stakeholders have participated in a forum discussing environmental design and how the built environment can support healthy lifestyles. The “Growing Green, Growing Healthy” committee convened a follow-up workshop, “Healthy General Plans,” to discuss how local county and city planning departments can integrate health and active living concepts into long-range general plans. Planning and public health professionals across the nation are adopting a new framework for neighborhood design that views the built environment as an opportunity to enhance public health. Transportation and community design factors can increase an individual’s risk of chronic disease, such as asthma, obesity, and diabetes, in addition to other adverse health outcomes, including pedestrian and motor vehicle injury, as well as violence. It is well documented that mitigation of environmental risk factors within transportation and community design can have a positive impact on health. A study conducted during the 1996 Atlanta Olympics documents that asthma-related emergency room visits decreased significantly (41.6 percent) when traffic was reduced and use of public transportation increased. Research from Saleans and Sallis (2003) demonstrated that residents of a

“walkable” San Diego neighborhood were more fit than demographically matched residents in a less-walkable neighborhood. Environmental risk factors that contribute to adverse health outcomes can include unsafe walking and biking conditions, lack of access to nutritious foods, poor air quality, and limited access to opportunities for daily physical activity. In San Diego County, several local governmental jurisdictions, including Chula Vista, La Mesa, and the City

Beyond the traditional numbers associated with health, such as blood sugar and weight, it is well documented that an individual’s address, ZIP code, and census tract can greatly impact health equity. and County of San Diego, are incorporating these public health ideas and language into planning documents. The COI “healthcare systems and providers” domain surveyed physicians to receive feedback on the most pressing needs and strategies to improve their practice relating to obesity. The results indicated a desire for trainings to enable physicians to become advocates in their community to assist in policy changes. Another need that is currently being addressed is a community resource directory to provide information on efforts to prevent and treat obesity. With 211 San Diego taking the lead, in collaboration with Rady Children’s Hospital and the COI as content experts, this directory is currently being developed. The healthcare systems and provider domain would welcome any physician interested in participating on this domain work group. If interested, please contact Cheri Fidler at cfidler@rchsd.org or at (858) 966-7748. Another local initiative, the Healthy Eating, Active Community (HEAC), which is based in Chula Vista and receives funding from the California Endowment, offers a unique project developed through the California Medical Association’s Obesity Prevention Project. This project was piloted with the HEAC by lead physician Chris

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Searles, MD. After the successful pilot, it has been extended to the COI government domain and works in partnership with County Parks and Recreation. The RecreationRx program empowers “Physician Champions” to advocate for health and obesity prevention in their area. The concept is to promote health through recreation by facilitating partnerships between healthcare and recreation providers and the communities they serve. The program promotes the benefits of physical and mental health as essential in any plan to change one’s lifestyle. The “Recreation Prescription” is an actual prescription for physical activity. It supports physician’s recommendations for healthy activity and social connections and builds community partnerships. To receive prescription pads, learn how to implement your own program, and receive updates and step-by-step guidance, visit RecreationRx.org. Grasping the concept of the social determinants of health and understanding how this principle links to health equity is vital to improving the health of patients, communities, and the nation. Overall, the health of San Diego County residents is improving in many key health outcomes, such as heart disease, stroke, infant mortality, asthma, and cancer. However, when we explore the prevalence and rates of these conditions by race and ethnicity, in some cases the numbers reveal differences among some groups. Our goal is to achieve health that is better than the best for all residents of San Diego County. Partnership with community stakeholders will be the key to this success. As physicians you are part of this solution. Note: To read this article with references, visit SDCMS.org.

A b o u t t h e A u t ho r : Dr. Woo-

ten, SDCMS and CMA member since 2006, is the public health officer for the County of San Diego, Health and Human Services Agency. She is board certified in family medicine and has a master’s degree in public health. From 1990 to 2001, she practiced medicine as a faculty member in the UCSD Department of Family and Preventive Medicine; she joined the County of San Diego in March 2001. Dr. Wooten remains a UCSD volunteer associate clinical professor and is an adjunct professor at SDSU’s Graduate School of Public Health.

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Technology Matters By Ofer Shimrat

Cloud Computing and Healthcare

Bad Weather or Sunny Forecast?

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with the inner workings of the remote application and only “see” and “use” the In current IT circles, the Internet is often AKT_SDP_08:Layout 1 being 8/22/08 3:52without PM Page 1 services requested, control referred to as The Cloud. Think of mulof the technology infrastructure to make tiple computers in a giant mesh all interit happen. working together. Now think of many such Keep that in mind when we traverse meshes and step back … see The Cloud? healthcare. Although you may not physically see it, The Cloud is there for all sorts of sigWho Uses Cloud Computing? nals: data, telephony, digital, etc. The term Almost everyone in this day and age with “Cloud Computing” denotes the use of an electronic communications device uses cloud- or Internet-based computers for a variety of services. In its historically short life span, its usage is still evolving as we speak.

What Is Cloud Computing?

one form or another of Cloud Computing — it is everywhere. Whether you are banking online with your computer, viewing GPS-aware restaurant reviews on your mobile device, or sending live digital media through your webcam, you are using services in The Cloud, i.e., not installed or contained within your local device. A case can be made that anytime you used dial-up in the early days of the Inter-

As definitions evolved and got refined, Cloud Computing now implies the user experience moving away from personal computers and into a “cloud” of computers. The expression “The Cloud” has its roots in telephony applications in the early 1990s. Telephone utilities were leveraging The Cloud for their switching and routing in order to deliver the proper connections for phone calls, faxes, live feeds, signals, etc. The Internet, in its infancy right around that same time, leveraged those connections to allow users to “dial up” and reach their intended Internet forum or tech support area. We now fondly look back at those times and wonder how business was conducted at “dial-up” speeds. By the turn of the millennium, the Internet was moving at much faster speeds — referred to as broadband — and all the computing equipment to make that happen was up “there” somewhere, and the term “in the cloud” became all the rage. Then, around the middle of the decade, “Cloud Computing” was firmly in the lexicon as a way to define what the user was doing: accessing computing services in the cloud. As definitions evolved and got refined, Cloud Computing now implies the user experience moving away from personal computers and into a “cloud” of computers. Users of The Cloud are not concerned

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net, you were leveraging The Cloud, but were you? Your computer was local, your software application was local, your data was local, and you were viewing it on your CRT monitor locally. Back then, all you were using the Internet for was to transmit and receive data that, once the transmission was complete, ended up locally. In the early part of the decade, companies like Amazon began architecting their websites in such a way that you could utilize their services simply through the use of a browser like Netscape or Internet Explorer. Soon after, other companies got into the fray, and, through the use of more robust technologies, “in the cloud” applications became more and more commonplace. By the middle of the decade, most major corporations with a large Web presence had working and mature renditions of their services completely “in the cloud.” Fast forward to now when companies like Google and Microsoft offer “in the cloud” services that require hardly any additional software on your local computer, beyond the operating system of the computer or device and a browser. Some services are offered for free by merely signing up, while others are offered as a recurring, monthly, per-seat subscription; schemes include Software as a Service (SaaS) and Application Service Providers (ASP). It is a trend and a pattern that is quickly gathering steam.

What Is Cloud Computing As It Applies to Healthcare? The trend appears to be irreversible. Many software applications, services, and data once in the realm of a local computer or local server safely secure in your building are now in the domain of the public Internet. Private health information once confined to these local networks is migrating, wholesale, onto the Internet. Patients voluntarily grant access to their health records every time they sign a waiver to the health insurer that then decides on the payment disposition to the doctor, pharmacy, or hospital. For the most part, the collection and organization of this data is completely legal. It then follows that companies want to automate and accelerate access to these records in order to offer “in the cloud” products and services to patients, doctors, and institutions. The fact that Google and Microsoft are heavily invested “in the cloud” extends to their new offerings for medical record services, such as Microsoft’s HealthVault and Google Health. While still in beta testing, these software giants have partnered with large healthcare providers for their programs: Microsoft with Kaiser Permanente and Google with The Cleveland Clinic. Microsoft and Google are two prominent examples of many other company offerings that are following the accelerating trend of placing previously local and private health records “in the cloud.” This

coming explosion of information will be stored in massive data centers around the world and will provide access to healthcare records for patients, insurers, doctors, pharmacies, and institutions. Interesting timing and fascinating convergence of events if you consider the new Obama administration initiatives like “Transforming Healthcare Through IT” and “Enabling Healthcare Reform Using Information Technology” — recommendations by the Healthcare Information and Management Systems Society (HIMSS) to the Obama administration and the 111th Congress.

How Will Cloud Computing Affect Your Practice? In the coming months and years, several factors are converging into a “perfect storm” of opportunity and challenges. For most solo, small-, and medium-size practices, Cloud Computing represents a juncture of significance. Do you invest up front and build your local computing in-

The fact that Google and Microsoft are heavily invested “in the cloud” extends to their new offerings for medical records services, such as Microsoft’s HealthVault and Google Health. frastructure and keep your data local or do you amortize your investment over recurring monthly charges and keep everything “in the cloud,” including your data? Either choice presents additional challenges: What about backups, disaster recovery and 99.999 percent uptime to the Internet? What about HIPAA compliance of these services and applications offered both as local and “in the cloud”? What about hybrid applications that leverage both local infrastructure and The Cloud? Carefully analyzing the options and acting prudently could mean the difference between bad weather and sunny forecasts when it comes to implementation time. By utilizing the SWOT analysis approach — strengths, weaknesses, opportunities, and threats — each practice could analyze

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the adoption of a unique computing infrastructure commensurate with their needs. The convergence of the technologies associated with Cloud Computing and the pronouncements laid out by the newly passed American Recovery and Reinvestment Act of 2009 (ARRA) will propel practices of all sizes to carefully consider their approach to their selection of the right electronic medical record application. According to the Certification Commission for Healthcare Information Technology (CCHIT), more than 300 vendors currently offer some variance of electronic medical records — some “in the cloud,” some locally, and some in both. They include: • Electronic Health Records (EHRs) • Electronic Medical Records (EMRs) • Personal Health Records (PHRs) • Payer-based Health Records (PBHRs) • Electronic Prescribing (E-prescribing) • Financial/Billing/Administrative System • Computerized Practitioner Order Entry (CPOE) Systems

The Bottom Line As part of your SWOT analysis, determine first which path your practice will take: local, “in the cloud,” or a hybrid of both. Then and only then procure your IT infrastructure to meet the software, hardware, and network requisites for that application, in that order. Correctly implementing and utilizing information technology will offer your practice enormous benefits — local, cloud computing, or a hybrid of the two. Your practice will have better access to healthcare services and information that would subsequently result in improved outcomes, fewer errors, and increased cost savings — a sunny forecast to be sure.

the A u t ho r : Mr. Shimrat is founder and CEO of SDCMSendorsed Soundoff Computing Corporation, a consultancy specializing in IT products and services. Originally an applications developer, he brings database methodology approaches to network implementations. He combines practical experience as a thrice business owner with best practices in providing organizations with needs analysis, business logistics, IT infrastructure, and proactive maintenance. Visit SoundoffComputing.com or call (858) 569-0300.

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Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

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Health Information

Technology

Electronic Health Record Buyers

Beware

By Stephen H. Carson, MD

n a recent open letter to President Obama, David Kibbe, a senior adviser to the American Academy of Family Physicians and expert on health information technology (HIT), described the current electronic health records (EHRs) as costly, difficult to use, and unable to allow hospitals, physician offices, or pharmacies to easily share information about patients’ medical histories and treatments. He wrote, “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the [tower of] Babel that already exists.” The following points should help physician buyers understand why physicians should approach EHRs and e-precribing tools with extreme caution: • Affordability. Most stand-alone EHRs cost a minimum of $10,000 per physician for purchase, installation, and staff training. Maintenance and upgrades can easily run up to $2,000 per year per physician. Subscriptions for EHRs typically cost $400 per month per physician.

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• Return on Investment: Although the government and health plans reap 90 percent of the financial benefit of EHRs, physicians are expected to pay for the efforts in time and money. For example, the current incentive dollars for e-prescribing and pay-for-performance may not amount to more than $3,500 per physician per year — hardly enough to offset the costs, let alone the headaches. Many of the incentives are not guaranteed for more than four years. • Reduction in Productivity: The average primary care physician will experience a 20 percent reduction in productivity and collections in the first year of using a full-blown EHR. Beyond the first year, productivity rarely surpasses what it was with paper records for PCPs. • Interoperability: Physicians who buy an independent e-prescribing tool or EHR that is not fully integrated with their practice management system for demographic data, billing, and collections will be frustrated with the ongo-

ing costs and headaches of making the two systems work seamlessly. Anytime there are upgrades to one system, there are unanticipated costs and glitches with the second system. There are also major interoperability issues between physicians and their hospitals, labs, and radiology vendors. This connectivity is necessary to eliminate the errors and the time associated with having to re-key patient data into your EHR. • Unexpected Downtime: Solo and small practices cannot afford dedicated technicians to solve problems inherent with electrical outages, computer glitches, and server crashes. • Changing Requirements: EHRs will need to incorporate ever-changing requirements for clinical decision support, order entry, data capture and information exchange between stakeholders. Physicians will be regularly forced to spend additional dollars to modify their information systems. Based upon the current incentive timetables, it is my recommendation that physicians should NOT start shopping for hardware or software until the fall of 2010, with the goal of launching in January 2011. Although some physicians may want to proceed sooner, my rationale for waiting is as follows: • Cost of both hardware and software will continue to drop over the next two years. • Functionality of fully integrated practice management and EHR systems is dramatically improving from month to month. EHRs of the next decade will need to include modules for population health improvement, clinical decision support, eligibility verification, charge capture, claims adjudication, HEDIS reporting, and interoperability. Although there are some excellent

products on the market today, none of the products is ready to meet the requirements that are expected to be in place within two years. • Microsoft Windows 7 is likely to replace Windows Vista in early 2010. • Open source platforms are likely to heat up the competition among vendors and drive the price of EHRs downward. New adaptations of Vista for the ambulatory physician will stimulate disruptive innovation. • Inexpensive and energy-efficient, thin client hardware will become an attractive option for physician offices. • Incentives for innovative programs run by state, federal, regional, health plan, and independent practice associations will continue to evolve. • Standardized patient ID cards and card readers that interface with practice management systems is a priority for the Medical Group Management Association (MGMA). MGMA estimates that machine-readable patient ID cards could save physician offices, health plans, and hospitals as much as $1 billion a year by eliminating unnecessary administrative efforts and denied claims. • Real-time claims adjudication through the EHR will allow physician offices to determine eligibility, deductible thresholds, and CPT codes for immediate adjudication and reimbursement of the office visit. This feature is where the real, long-term financial reward is for physicians. • Standards: Under the stimulus act, the Office of the National Coordinator (ONC) for Health Information Technology will require EHRs to adopt new sets of standards, specifications, and certification criteria by December 31, 2009. These new standards will re-

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sult in unanticipated upgrade costs for those who have already purchased an EHR. • ICD-10 code sets are likely to be required by October 2013 and require tighter integration between clinical and billing functions. • FDA Barriers: The FDA still prohibits the use of e-prescribing modules to submit prescriptions for controlled substances. This explains why fewer than 5 percent of all prescriptions in the United States have been filed electronically over the last year. What about the HITECH Act in the American Economic Recovery and Reinvestment Act? It is estimated that $17.2 billion of the $20 billion dollars set aside to stimulate IT adoption will be in the form of incentive programs under Medicare and Medicaid. As currently written, ambulatory physicians participating in Medicare will be eligible if they can demonstrate

“If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the [tower of] Babel that already exists.” that they are “meaningful users” of certified EHR technology (standards are to be established before December 31, 2009). “Meaningful use” is defined as being connected in a way that improves the quality using measures selected by the ONC. Incentives will be limited to 75 percent of Medicare-allowed charges in any year and up to $44,000 over five years. Physicians

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Health Information

Technology

practicing in health professional shortage areas can receive an additional 10 percent. Physicians who start after 2014 will not receive any incentives. For Medicare-covered services rendered during 2015 or after by a professional who cannot demonstrate meaningful EHR use, the Medicare physician fee schedule will be reduced by 1 percent for 2015, 2 percent for 2016, and 3 percent for 2017. There is an escape clause for professionals who can demonstrate significant hardship, but that clause will apply to a professional for a maximum of five years.

Do not buy separate practice management and EHR systems in the hope that they will always work well together. Unfortunately, the money from the Medicare and Medicaid programs will be paid out over four or five years and won’t be available until 2010 or 2011. The Act provides for comparable incentives and disincentives for professionals providing substantial services through Medicare Advantage plans. The Act also provides for payments to those states that have approved Medicaid plans and programs to encourage the adoption and use of certified EHR technology. Specifically, these states will receive 100 percent of the payment outlays of their programs and 90 percent of their costs of administering such programs. Payments to physicians cannot exceed 85 percent of average allowable costs for certified EHR technology and are capped at $25,000 for the first year and $10,000 for subsequent years. These amounts will be reduced by two-thirds of that amount for pediatricians. Eligible providers must have at least

a 30 percent Medicaid patient load, and pediatricians must have at least a 20 percent Medicaid patient load. Federally qualified health centers or rural health clinics must see at least a 30 percent load of patients classified as “needy,” which is broader than Medicaid beneficiaries. For those of you who are ready to make the leap despite the challenges, I would offer the following advice: • Purchase a fully integrated practice management system and EHR. Do not buy separate systems in the hope that they will always work well together. Make sure the integrated system supports the full set of HIPAA transaction standards, appointment scheduling, patient reminders, electronic eligibility verification, advanced claims editing (including health savings accounts), automated payment posting with electronic remittance advice, integrated credit card processing, configurable reporting, the ICD-10 code sets, and, if necessary, specialized Medi-Cal claims processing that addresses medical home requirements. In addition, do not forget to research the ability of the system to interface with health plans and clearinghouses. • Do not waste your time on stand-alone e-prescribing — you are only going to have to dump it later for an EHR. Remember, the incentives from Medicare for e-prescribing drop to 1 percent in 2012, to 0.5 percent in 2013, and then they disappear. • Pick an EHR suited to your specialty. Get advice from your colleagues and your specialty society. For example, voice recognition in the EHR is often a big plus for surgeons and enables savings on transcription costs. Look for software that automatically flags common tasks that are unique for your specialty (e.g., cancer screenings for

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internists and family practitioners). • Vendor Reputation: Pay attention to the vendor’s track record for service and support. • Interoperability: If possible, find an EHR that can receive data from your preferred lab and hospital and deliver patient-specific data into the correct field in each of your patients’ electronic charts. • Application service providers using a subscription model for maintaining and servicing your office is the best approach for physicians in small- and medium-size practices. • Workflow Planning, Staff Training, and Implementation: An experienced vendor will work with physicians and their staffs to map out the ideal workflow for the office and develop a carefully planned out schedule for training and implementation. Physicians should not underestimate the time or importance of these efforts. • Check the 2008 Best in KLAS Awards based on customer satisfaction with healthcare information technology vendors and consultants.

A b o u t t h e A u t ho r : Dr. Car-

son, SDCMS and CMA member since 1983, has for the past 25 years served as a consultant for health systems, schools of medicine, health plans, hospitals, and medical groups. In 1992, Dr. Carson founded Primary Care Associates (PCA), an independent practice association of 80 primary care physicians and more than 300 specialists serving the north coastal region of San Diego County. Dr. Carson served as the chief medical officer for the San Diego County Medical Society Foundation from 2005 through 2008. He continues to practice pediatrics and pediatric pulmonary medicine in Hillcrest.

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E-prescribing

Resources

Partners with:

Integrated Communications & Data

Available to Members at SDCMS.org By Lauren Wendler

-prescribing is the electronic generation, transmission, and filling of a prescription. It strives to reduce the number of medication errors and adverse drug effects, and improve standards in patient safety. Surescripts-RxHub is a network that securely links eprescribing systems to the major health plans, pharmacy benefit managers, and pharmacies. Prescribers have the choice of using a standalone solution or a system integrated with an EMR (electronic medical record). For 2009, the e-prescribing Medicare incentive will provide 2 percent of the total estimated allowed charges for professional services covered by Medicare Part B as provided by an eligible prescriber during one calendar year. Certain CPT codes must be used for at least 10 percent of the total Medicare Part B-allowed charges to be eligible. The list of codes can be found in Medicare’s “Guide to E-prescribing” (available at SDCMS.org). Before a physician makes the adoption decision, evaluating the current state of the practice is important in order to prevent future adoption failures. It is hard to put a finger on which vendor has the best e-prescribing product for your practice. Located on SDCMS’ web-

Electronic Medical Records

TCS_SDP_08:Layout 1

site are tools to help physicians research e-prescribing vendors, using a vendor-neutral approach. The resources available to members at SDCMS.org to help educate them and their staffs in e-prescribing include: • SDCMS E-prescribing webinar — “E-prescribing for Dummies” (filmed February 24, 2009) — along with a PowerPoint presentation. • AMA’s “Clinicians Guide to Eprescribing.” • Medicare’s “Guide to E-prescribing.” • Illumisys’ PowerPoint presentation: “The Benefits of E-prescribing.” • National E-prescribing Patient Safety Initiative webinar: “E-prescribing: Facts and Myths” (filmed October 9, 2008). Please contact me, Lauren Wendler, your office manager advocate, at SDCMS at (858) 300-2782 or at LWendler@SDCMS.org should you have any questions.

About

the

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Page 1 Endorsed by:

A u t ho r :

Ms. Wendler is your office manager’s SDCMS office manager advocate and can be reached at (858) 300-2782 or at LWendler@ SDCMS.org.

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Health Information

Technology

The American Recovery and Reinvestment Act of 2009 (HR1) Explanation of Health Information Technology Provisions (1)

By the american medical association

he “American Recovery and Reinvestment Act of 2009” (ARRA) provides substantial financial incentives ($19 billion over a specified five-year period) that will help physicians purchase and implement HIT systems. Beyond adequate financing, a key element to the widespread adoption and use of HIT is the development of uniform electronic standards that allow various HIT systems to communicate with each other. ARRA requires the Department of Health and Human Services (HHS) to develop such standards by December 31, 2009. Beginning in 2011, Medicare physicians who implement and report meaningful use of electronic health records (EHR) will be eligible for an initial incentive payment up to $18,000. While ARRA includes a provision that will reduce Medicare payments (starting at 1 percent) for physicians who do not use EHR systems, this does not take effect until 2015, and there are exceptions for significant hardship cases. As noted below, some of the details on the implementation of ARRA’s HIT-incentive provi-

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sions will be worked out through the regulatory rulemaking process in the coming months. AMA will be closely monitoring and providing input to ensure that the HIT provisions are implemented in a manner consistent with the intent of ARRA.

HIT Incentive and Penalty Program ARRA provides financial incentives through the Medicare Part B program to encourage physicians to adopt and use qualifying EHRs in a meaningful way. Meaningful use of EHRs will be defined by HHS during the rulemaking process and may include reporting requirements on quality measures. ARRA also authorizes HHS to provide competitive grants to states to make loans available to healthcare providers to assist them with HIT acquisition and implementation costs. Physicians (non-hospital based) are eligible for Medicare incentive payments based on an amount equal to 75 percent of the allowed Medicare Part B charges — up to a maximum of $18,000 for early

adopters whose first payment year is 2011 or 2012. The secretary of HHS will define the reporting period(s) with respect to a payment year. Incentive payments would be reduced in subsequent payment years, eventually phasing out in 2016. Physicians who do not adopt/use an EHR system before 2015 will face a reduction in their Medicare fee schedule of 1 percent in 2015, 2 percent in 2016, and 3 percent in 2017 and beyond. The secretary of HHS has the authority to make exceptions to this reduction on a case-by-case basis for physicians who demonstrate significant hardship (e.g., a physician who practices in rural areas without sufficient Internet access). The following table shows how the incentives and potential reductions are expected to work from 2010-2017 (2, 3): First Payment Year

$63,750, over a six-year period. In the event that the secretary of HHS finds that the proportion of healthcare providers who are meaningful users of EHRs is less than 75 percent, the secretary is authorized to increase penalties beginning in 2018, but penalties cannot exceed -5 percent.

ARRA Will Establish HIT Policy and Electronic Standards ARRA formally establishes the role and functions of the Office of the National Coordinator for Health Information Technology (ONCHIT) within HHS, which is to promote the development of a nationwide interoperable HIT infrastructure. (ONCHIT was already created by Executive Order in 2004.) ARRA establishes the HIT Policy and

First Payment Year Amount and Subsequent Payment Amounts in Following Years

Reduction in Fee Schedule for Non-adoption / Use

2011

$18k, $12k, $8k, $4k, and $2k

2012

$18k, $12k, $8k, $4k, and $2k

2013

$15k, $12k, $8k, and $4k

2014

$12k, $8k, and $4k

2015

-1 percent of Medicare fee schedule

2016

-2 percent of Medicare fee schedule

2017 and thereafter

-3 percent of Medicare fee schedule

Incentives under the Medicaid program are also available for physicians, hospitals, federally qualified health centers, rural health clinics, and other providers; however, physicians cannot take advantage of the incentive payment programs under both the Medicare and Medicaid programs. Eligible pediatricians (non-hospital based), with at least 20 percent Medicaid patient volume, could receive up to $42,500, and other physicians (non-hospital based), with at least 30 percent Medicaid patient volume, could receive up to

Standards committees, which comprise public and private stakeholders (e.g., physicians) to provide recommendations on the HIT policy framework, standards, implementation specifications, and certification criteria for EHRs. HHS is required to adopt, through the regulatory rule-making process, an initial set of standards, implementation specifications, and certification criteria by December 31, 2009, for qualifying EHRs. ONCHIT is authorized to make avail-

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able a qualifying EHR system to healthcare providers for a nominal fee. AMA will be seeking clarification from HHS on the cost of such a system and the date it will be available. Physicians do not need to purchase the government’s EHR system; they can purchase any qualifying system (i.e., meets certain standards, including interoperability) from a vendor of their choice. AMA policy strongly supports positive financial incentives for physicians to acquire and implement HIT. Throughout the legislative process, AMA urged flexibility in the timeline for HIT adoption and use, given the uncertainties surrounding the readiness of standards, the availability of EHR systems that are interoperable, secure, and affordable, and the rule-making process. AMA will continue with efforts to ensure that physicians obtain the funds and assistance they need to transition their practices from paper to electronic-based systems. Notes: 1) This summary will be updated when additional details become available during the rule-making process. 2) Physicians in rural health professional shortage areas who adopt/use EHRs are eligible to receive a 10 percent increase on the incentive payment amounts described. 3) Physicians who report using an EHR system that is also capable of e-prescribing will no longer be eligible for the eprescribing bonuses established by the “Medicare Improvements for Patients and Providers Act” (MIPPA); they will be eligible for HIT incentives only to avoid “double-dipping.” Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR.

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Health Information

Technology

HIT Stimulus Could Bring $3 Billion in New Funds to California CHCF Issue Brief Analyzes Opportunities and Recommends State Action

he federal stimulus bill signed by President Barack Obama in February offers unprecedented opportunities to increase health information technology (HIT) adoption among California providers and facilitate the secure exchange of patient health information, according to a February 23, 2009, issue brief published by the California HealthCare Foundation (CHCF). The Health Information Technology for Economic and Clinical Health Act (HITECH), a component of the American Recovery and Reinvestment Act (ARRA) of 2009, provides roughly $36 billion in outlays for health information exchange infrastructure and incentive payments to physician practices adopting electronic health records (EHRs), chronic disease management systems, and other technologies. In California, the stimulus funding could add up to more than $3 billion, according to the issue brief. CHCF’s issue brief outlines necessary steps to take advantage of these provisions and makes specific recommendations to Governor Schwarzenegger and the Cali-

fornia Legislature to ensure that California successfully competes for and makes effective use of HITECH funds. The key recommendations include: • Appoint a Deputy Secretary of Health Information Technology, within the Health and Human Services Agency, to coordinate and drive health IT and health information exchange planning and implementation. • Appoint a nonprofit “state-designated entity” to apply for HIE implementation funding on behalf of the state. • Establish policies, procedures, and information systems required to support Medi-Cal incentive payments for adoption of EHRs by physicians, hospitals, community health centers, and others. • Actively engage with federal officials and policymakers to ensure California has a meaningful voice at the table during the regulatory process that will determine the HITECH Act’s specific funding mechanisms. • Appropriate funds in the amount required to match the federal funding

By The California HealthCare Foundation

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authorized under the HITECH Act in order for California to take full advantage of the opportunities available through the Act. •T ake steps to educate patients, consumers, and the public on existing health privacy safeguards and new protections intended to ensure the confidentiality and security of personal health information. For the past 10 years, CHCF has worked to accelerate the adoption and effective use of new information technologies in healthcare, pushing for national data standards, interoperable systems, development of patient privacy protections, and promoting use of patient-centered and patient-

In California, the stimulus funding could add up to more than $3 billion. controlled tools for self-management of chronic conditions. To access “An Unprecedented Opportunity: Using Federal Stimulus Funds to Advance Health IT in California,” visit CHCF.org.

A b o u t t h e A u t ho r : The Cali-

fornia HealthCare Foundation (CHCF) is an independent philanthropy committed to improving the way healthcare is delivered and financed in California. By promoting innovations in care and broader access to information, CHCF’s goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford.

Time Well Spent?

Other CHCF Publications Accessible at CHCF.org Electronic Health Records: • Physician Practices: Are Application Service Providers Right for You? First Consulting Group (October 2006) at www. chcf.org/topics/view.cfm?itemID=125716 • Electronic Health Records Versus Chronic Disease Management Systems: A Quick Comparison (March 2008) at www.chcf. org/topics/chronicdisease/index.cfm?itemID=133586 • Open-source EHR Systems for Ambulatory Care: A Market Assessment (January 2008) at www.chcf.org/topics/view. cfm?itemID=133551 • Creating EHR Networks in the Safety Net (April 2008) at www.chcf.org/topics/view.cfm?itemID=133595 Electronic Prescribing: • Getting Connected: The Outlook for Electronic Prescribing in California (November 2008) at www.chcf.org/topics/view. cfm?itemID=133793 • The Prescription Infrastructure: Are We Ready for E-prescribing? (January 2006) at www.chcf.org/topics/chronicdisease/index.cfm?itemID=118337 Personal Health Records/Consumers: • The Wisdom of Patients: Healthcare Meets Online Social Media (April 2008) at www.chcf.org/topics/chronicdisease/ index.cfm?itemID=133631 • Perspectives on the Future of Personal Health Records (June 2007) at www.chcf.org/topics/chronicdisease/index.cfm? itemID=133289 • Whose Data Is It Anyway? Expanding Consumer Control over Personal Health Information (February 2008) at www. chcf.org/topics/view.cfm?itemid=133577 • Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools (June 2008) at www.chcf.org/topics/view. cfm?itemID=133659

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Telehealth: • Telemedicine in California: Progress, Challenges, and Opportunities (July 2008) at www.chcf.org/topics/chronicdisease/index.cfm?itemID=133682 • Delivering Care Anytime, Anywhere: Telehealth Alters the Medical Ecosystem (November 2008) at www.chcf.org/topics/view.cfm?itemID=133787 Other Related Resources: • Snapshot: The State of Health Information Technology in California, 2008 (January 2008) at www.chcf.org/topics/ chronicdisease/index.cfm?itemID=133552 • Gauging the Progress of the National Health Information Technology Initiative: Perspectives From the Field (January 2008) at www.chcf.org/topics/view.cfm?itemID=133553 • Open Source Software: A Primer for Healthcare Leaders (March 2006) at www.chcf.org/topics/view.cfm?itemID=119091

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Health Information

Technology

The Infobutton Knowledge-based System Meets EHR By Craig Haynes

he development and deployment of the electronic health record (EHR) provides opportunities for improved information management on both the back end (administration) and the front end (user interface). On the back end, the hope is that with interoperable systems, healthcare organizations, doctors, patients, and insurers will become more efficient, more proficient, and safer. Moreover, there is also the hope that costs, if not reduced, will at the very least be contained. On the front end, the hope is that the EHR interface will make not only patient information more accurate, timely, and accessible, but that it will also do the same for knowledge-based information. The Infobutton is a developing technology created in order to provide contextual, timely delivery of knowledge-based information to caregivers from within the EHR environment, i.e., at the point of care. The Infobutton is an integrated application within the EHR that, when executed, creates a query to a linked, preselected medical reference. In addition, the Infobutton is also designed to extract

specific data tagged in the patient record, such that an Infobutton embedded next to the diagnosis of pulmonary hypertension in the EHR of Jane Doe, age 45, will provide a medical reference relevant not only to pulmonary hypertension, but, if tagged (searchable), the entry will also match the demographic data in the patient’s record, as well as any other searchable attributes tagged in the patient’s record. (See Illustration: The Infobutton appears as a dot next to the items listed in the patient record under the headings: “chief complaints,” “active diagnoses,” etc.) HL-7® (the ANSI standards development organization) has developed a standard for the design and implementation of Infobutton technology, and there have been several early adopters among clinical information system (CIS) vendors and medical reference publishers. There are many questions and issues that arise when considering Infobutton technology for a CIS. These questions vary depending on the healthcare setting, the CIS vendor, and the expertise available to advise customers on such matters. The leading CIS vendors (EPIC®, Cerner®,

GE®, McKesson®, et al) have partnerships with content publishers (e.g., Micromedex®, Elsevier®, et al) and some endeavor to sell “package” deals to CIS buyers. Publishers supporting content integration will work with existing CIS customers (i.e., those who already have a CIS contract) in order to deploy the Infobutton technology — sometimes for an additional, annual licensing fee. Customers should determine if their CIS has a partnership with the publisher in question and, if not, determine if the two parties can work together to deploy the technology. At large healthcare organizations with medical libraries and professional librarians, it is highly advisable that the organization’s CIS implementation team work directly with the library to determine existing electronic content licenses. Licensing the same content twice is not a desirable outcome. In smaller, private practices and non-acute-care settings, working with users and the vendor to determine the knowledge-based system needs of the practice/ setting is definitely worth the investment of time. For example, if the practice already licenses Dynamed® or UpToDate®, and the clinicians are happy with this content, they should work with the publisher and the CIS vendor to determine if either or both support the HL-7 Infobutton API Standard, and then seek to deploy it. On the CIS side, buyers should beware of vendors “including” knowledge-based systems or Infobutton links to content of unknown origin. Stay with name-brand clinical content providers, such as Elsevier®, Micromedex®, Wolters-Kluwer®, et al. These publishers have the resources to maintain and update their content on a regular basis and to provide technical support and training. On the publisher side, verify that the content provider supports one or more of the industry standard controlled vocabularies supported by the CIS (e.g., ICD9-CM®, MeSH®, SNOWMEDCT®, et al) and that the publisher is committed to expanding its content tagging and meta-data.

the A u t ho r : Mr. Haynes is head of the UCSD Medical Center Library.

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Corporate Legal Services Receive a free consultation and discounts on corporate legal services. Call Ladd Young Attorneys at Law at (619) 5646696. San Diego County Physician Mailing Lists Receive one free physician mailing list annually and a discount on all additional mailing lists requested in the same year. Contact SDCMS at (858) 5658888. SDCMS Membership Certificate Receive a free SDCMS membership certificate. Contact SDCMS at (858) 565-8888. Investments Invest with Dunham & Associates and discount your SDCMS dues by $150. Call Jeff Dunham at (619) 308-9700. SDCMS Pictorial Membership Directory Appear in SDCMS’ annual pictorial membership directory. Receive a free directory each year and a 50% discount on additional directories purchased, as well as discounts on directory advertising. Contact SDCMS at (858) 565-8888. Coding Hotline Access a free coding hotline (provided by CHMB Solutions). Email your coding question(s) to SDCMS at Coding@SDCMS.org. San Diego Physician Magazine Receive a free subscription to the voice of San Diego County’s physicians. Place free classified ads and discounted display ads. Contact SDCMS at (858) 5658888. San Diego Magazine Receive a gift subscription (active physician members) or a discounted subscription (resident physician members). To sign up, contact SDCMS at (858) 565-8888. To update your subscription address, contact San Diego Magazine at (888) 3500963 or at sdgm@kable.com. SDCMS Email Newsletter, “News You Can Use” Receive the latest in medical, local, state, and federal news critical to your practice … free to members and free of advertising. Contact SDCMS at (858) 5658888. SDCMS Seminars SDCMS member physicians and their office staff attend free

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Local, State, and Federal Physician Advocacy SDCMS and CMA continue to be vigilant in our protection of MICRA, in fighting against non-physician scope of practice expansions, in working closely with our political representatives and other healthcare stakeholders to fix our broken healthcare financing system, and in doing everything we need to do to protect physicians’ interests wherever they are challenged. Contact SDCMS at (858) 5658888. Full-time SDCMS Physician Advocate Have a question? Don’t know where to begin? Contact your fulltime, SDCMS physician advocate, Marisol Gonzalez, free of charge, to get the answers to all your questions, at (858) 300-2783 or at MGonzalez@SDCMS.org. Full-time SDCMS Office Manager Advocate Let your office manager and staff know that they have a full-time office manager advocate on staff at SDCMS ready to help them with any questions they may have, free of charge. Contact Lauren Wendler at (858) 3002782 or at LWendler@SDCMS.org. SDCMS News Alerts Stay informed of the news that affects your bottom line and your patients’ health with faxed and emailed alerts sent by SDCMS to you, free of charge … and free of advertising! Contact SDCMS at (858) 565-8888. SDCMS and CMA Websites Access members-only SDCMS and CMA websites to find valuable resources, such as a list of San Diego County physician NPIs, updated weekly. Contact SDCMS at (858) 565-8888. Engagement in Healthcare Issues Be part of the solution! Become

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Leasing, Renewals & Sales: Call the Healthcare Real Estate Specialists at Colliers International for a complete inventory of all available medical office space for lease or for sale in your area, or for valuable vacancy and absorption information. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase to assure you obtain the best possible terms. There is no charge for our consulting services. Contact Chris Ross at 858.677.5329 email chris.ross@colliers.com

MEDICARE-CERTIFIED SURGERY CENTER: Reasonable rates for use of Medicare-certified surgery center. Call (619) 464-9876 and speak to Mira. [694] LA MESA OFFICE SPACE: Office space available in beautiful Victorian house in La Mesa. Call (619) 464-9876 and speak to Mira. [693] SPACE FOR LEASE: Beautiful office space available for lease in a booming location — located just outside of downtown San Diego, with ocean views, and a beautiful skyline. The space available includes two exam rooms and a physician’s office. Common areas include a third exam room for overflow, a lobby, kitchen, chart room, storage, front desk, and nurse station. The practice is fully equipped and fully staffed. Includes an EMR system, which means this is a paperless office! The staff is very friendly, and the office manager extremely experienced. New doctor may choose to join the team or practice solo. This is a family practice, but the team also includes a PT chiropractor and podiatrist. Please contact info@promed-financial.com or (888) 277-6633 for details. [692]

NEWLY REMODELED CORNER BUILDING IN HILLCREST (1295 UNIVERSITY AVE, 2ND FLOOR): Flexible space between 300 and 10,000ft2, space can be configured according to requirements, front offices have large windows overlooking University Avenue. Covered, secured parking, two elevators, granite flooring in the entrance, staircase, and elevators; ADA bathrooms and electric doors. Near major hospitals, freeway 163, public transportation and Ralphs shopping center. Generous tenant improvement allowances possible with long-term lease. Lease terms and rent negotiable. Available April 2009. Please call (858) 212-4562 or email samimi9@ gmail.com for more information. [689] OFFICE AVAILABLE ON SCRIPPS ENCINITAS LOT: In desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior designer renovation. Includes doctor’s desk, your own exam room, front desk, common waiting area, staff bathroom including shower, and kitchen. Contact us at San Diego Vein Institute at (760) 944-9263. [688] MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, EL CENTRO, CA: In historic downtown area, near County offices, courthouse, and El Centro Regional Medical Center. Prime location; build to suit, and competitive rates with tenant incentives. 6,000ft2 can be divided; with private entrances. Near I-8 and public transportation with ample parking. Visit website for 441 West State Street at http://info.svn.com/Dottie. Surdi. Direct inquiries to (858) 349-2007 or dottie.surdi@svn.com. [686]

NEW MEDICAL BUILDING ALONG I-15: Pinnacle Medical Plaza is a new 80,000 SF building recently completed off Scripps Poway Parkway. The location is perfect for serving patients along the I-15 from Mira Mesa to Rancho Bernardo and reaches west with easy access to Highway 56. Suites are available from 1,000—11,000 SF and will be improved to meet exact requirements. A generous improvement allowance is provided. For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, YUMA AZ: Directly across from new Yuma Regional Medical Center. Prime location; build to suit, and competitive rates with tenant incentives. Ideal for sole practitioners. 1,000ft2 suite with private entrance or 700ft2 within the clinic. Ample onsite parking, public transportation nearby. Visit website at 2475 South Avenue A http://info.svn.com/Dottie.Surdi. Direct inquiries to (858) 349-2007 or dottie.surdi@svn.com. [685] SUITES FOR LEASE, MISSION VALLEY PROFESSIONAL MEDICAL/OFFICE BUILDING:

Prime location, build to suit, and competitive rates with tenant incentives make this a fabulous value. Suites approximately 1,000ft2. At RT 15 and RT 8, just minutes from six major hospitals. Ample parking. Easy freeway access and public transportation nearby. Visit website for Riverview Center, 3633 Camino del Rio South at http://lease.svn.com/3633Camino. Direct inquiries to (858) 349-2007 or dottie.surdi@svn. com. [684] POWAY OFFICE SPACE TO SUBLET: Newly remodeled, 3,000ft2 office space to sublet. Ground level, high-end medical office building with easy access from both the 56 and 15. Separate administrative space with possible procedure room available. Please contact (858) 6686502 or hsears@sdcpms.com. [683]

Class “A” Medical building for sale or lease: 3-Story, 55,450/SF located at 838 Nordahl Road in San Marcos, CA. Suites from 1,000/ SF. Premier location. Easy freeway access & close proximity to restaurants & Sprinter. Shower & locker facilities. Resort quality restrooms. Tropical landscaping. Koi ponds. Panoramic views. Latest in “green” building design standards with utility cost savings. Scheduled for completion in May 2009. For more information contact Mark Avilla (760) 431-4223 mavilla@breg.com www.nordahlmedicalcentre.com www.brecomercial.com OFFICE SPACE TO SHARE: Low-volume family medicine physician has space to share in his 1000ft2 office at 285 N. El Camino Real in Encinitas. Can reserve as little as one half-day per week. Please call or email Marty at (760) 4367464 or at mschulman@ucsd.edu. [682] HILLCREST MEDICAL OFFICE ACROSS FROM SCRIPPS MERCY HOSPITAL: Office sublet available in the Mercy Medical Building directly across from Scripps Mercy Hospital. Great space for an adult primary care or a specialist. First floor, excellent staff, T1 line, EHR capable, voicemail, website, and more! Call for more information and a tour: (619) 205-1480. [674] OFFICE SPACE FOR LEASE: Hillcrest, Mercy Medical Building (4060 Fourth Ave., 6th floor). 1947 usable square feet, consisting of four exam rooms, one large OR-style procedure room, two business offices, large waiting area, and small lab area. Beautiful views of San Diego. Copious shelves for medical files. Reception counter. T1 capability, and 220 volt outlet. Please call (858) 361-7300 or the onsite building manager at (619) 293-3081. Available by the end of January 2009. [671]

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.

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SDCMS Foundation Project Access San Diego Project Access San Diego is a NEW and INNOVATIVE project designed to coordinate healthcare volunteerism here in San Diego County. Together we can ensure that our vulnerable populations have access to needed healthcare services.

Your commitment to Project Access is required for our success. We want to make it easy for you to participate, so Project Access provides the following case-management services to enrolled patients: • Enrolling Patients Based on Need: We verify financial status so that you can be assured that your volunteer service is reaching those who are most in need. • Making Appropriate Referrals: We use referral guidelines that ensure that when a Project Access patient comes to your office, he or she can take full advantage of the visit. • Providing Enabling Services: We provide services such as transportation and translation so that you don’t have to wonder if a patient is going to miss an appointment or if there will be a language barrier. • Providing Case Management Services: We work with each patient one-on-one to coordinate follow-through on all medical needs. • Providing All Needed Services: Through our partnerships, we ensure that a full scope of services is available to all of our patients, from office visits, hospital services, and even a defined pharmacy benefit. Project Access is actively recruiting physicians, hospitals, and ancillary service providers to participate in the program.

Please make a commitment today. Visit our website at SDCMSF.org to learn more and sign up.

We need your volunteer commitment to help even one patient. A p r i l

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Classifieds OFFICE SPACE TO SHARE: Currently occupied by orthopedic surgeon situated in La Mesa. Five minutes away from Alvarado Hospital and 10 minutes from Grossmont Hospital. Looking to share with part-time or full-time physician. Fully furnished, fully equipped, with X-ray equipment and three exam rooms. Please call (619) 6680900 or email either rcham1000@aol.com or carmen@drcham.com. [666] LA JOLLA OFFICE SPACE AVAILABLE AT XIMED MEDICAL BUILDING: Brand new, renovated office space available, preferably to a primary care MD to share. This is a rare opportunity to have a presence at the prestigious XiMed Medical Building right next to Scripps Memorial Hospital and to reduce your overhead by sharing space. Currently, the office is being used by a single physician part of the time. Flexible to any arrangement proposed. Call (858) 837-1540 or email melkurtulus@hotmail.com. [664] MEDICAL OFFICE SPACE FOR LEASE IN ENCINITAS: Available August 2009. Share space with established physician-owner. Office located in new LEED-certified professional office development on Encinitas Blvd., close to 5 freeway, Scripps Hospital, and public transportation. Free parking, private bathroom, front desk area, and additional storage space included. One to two offices 11x14 are available full or part time. Affordable lease rate in desirable area. Contact Wendy Khentigan, MD, at (760) 845-0434 or at wendykmd@aol.com. [646] ACROSS FROM SHARP CHILDREN’S HOSPITAL: Beautifully furnished, fully equipped 2,000ft2 office with five exam rooms. Share with a part-time physician. Please call (619) 8238111 or (858) 279-8111. [385] MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS): OB/GYN-type consultation room and one to two exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door. Free parking. Perfect for low-volume hospital campus consultations one to five half-days per week. Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557] OFFICE SPACE AVAILABLE: Office space at the corner of 8th Ave. and Washington St. in Hillcrest. Surgical center in building. Ample parking and simple freeway access. Close proximity to Scripps Mercy Hospital. Call (619) 297-6100 or email rbraun@handsrus.com. [555] PHYSICIAN POSITIONS AVAILABLE PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR: Temecula independent diagnostic testing facility seeks physicians to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month. Typically scheduled for nine-hour day shifts. Candidates must have California license. Please contact Robert at (619) 819-6528 for more information, or submit your CV via fax to (619) 342-4733 for immediate consideration. [699] URGENT CARE: Busy practice established in 1982 in East County seeks a part-time (with pos-

sibility of becoming full-time) physician. Please fax CV to (619) 442-2245. [698] OB/GYN: Well-established, busy OB/GYN practice next door to Mary Birch Women’s Hospital needs part-time associate with option to transition to full time. Inquires (858) 560-6200. [687] PRIMARY CARE PHYSICIAN FOR VETERANS HOME CHULA VISTA: The Veterans Home Chula Vista is currently seeking an additional primary care physician to provide medical care for veterans. The Veterans Home Chula Vista is a multi-care level facility with capacity for 400 residents consisting of three independent living retirement units with 165 beds; a Residential Care Facility for the Elderly (RCFE) assisted living unit with 55 beds; and a Skilled Nursing Facility (SNF) with 180 beds. The tentative start date is July 2009. This position requires experience in adult primary care medicine and preferably long-term care medicine. If you are interested in a career with our agency, please contact Paul Wagner, MD, at paul.wagner@cdva.ca.gov. [680]

FAMILY PRACTICE POSITION: • Solo Family Practice with partner • Position to replace retiring senior partner • No nights, weekend call or hospitalization • Full spectrum Family Practice • Well established patient base • Full time or part time (3 days minimum) • Upscale location and office Call Peter Graham, Broker 858-395-9928 Call Sally at 858-736-5818

SENIOR PHYSICIAN, HIV/STD/HEPATITIS BRANCH, COUNTY OF SAN DIEGO: Are you looking for a rewarding career that spans individual patient care and county-wide public health program development? As the medical director of the County STD clinic that provides HIV screening, diagnosis and treatment for sexually transmitted diseases, and hepatitis immunization, the Senior Physician manages a team responsible for providing excellence in clinical services. We are looking for a candidate who has strong leadership skills and the ability to work collaboratively with team members. Functional application of data, aptitude with technical writing and the desire to build bridges in the community are also desirable skills. We require a license to practice medicine in the State of California and at least three (3) years of post-internship training. Particularly suitable is a background in Internal Medicine, Family Practice, Ob-Gyn, Urology or Infectious Diseases. Please be aware that availability to work flexible schedules at multiple sites, including some evenings, is expected. If you meet the above, we are interested in YOU! Please visit www.sdcounty.ca.gov/hr to file an application. [675]

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MOONLIGHTING PSYCHIATRIST WANTED: Flexible 1+ weekends/month at Pomerado Inpatient Geropsychiatric Unit. Must be board eligible or board certified. $200+/hr. Contact Jason Keri, MD, at (619) 299-4374. [676] PT/FT PSYCHIATRIST WANTED: To join respected multi-specialty group serving nursing homes. Office and hospital optional. Partnership and growth opportunities. Highly flexible schedule. $180k+. Contact Jason Keri, MD, at (619) 299-4374. [677] INTERNAL MEDICINE PRIVATE PRACTICE, UNUSUAL FLEXIBILITY, UNIQUE OPPORTUNITY: North San Diego County, part-time position, looking for board-certified internist. If interested, please call (619) 248-2324. [668] NEUROLOGY POSITION: Position available immediately for board-certified/board-eligible neurologist in Mission Valley. Experience with forensics or workers’ compensation preferred. Physician must go out on medical leave and needs coverage. This is a very busy practice that does include some pain management. Currently we have an MD with musculoskeletal experience (fellowship at UCLA in acupuncture) and foreign graduate MD serving as PA to assist with practice. Position has potential to evolve into permanent position or partnership depending upon compatibility issues. Respond to dovemd@ sbcglobal.net for further details. [667] KAISER PERMANENTE — CARDIOLOGY EPS OPPORTUNITY: At Kaiser Permanente Southern California, we believe our achievements are best measured by the health and wellness of the community we serve. That’s why we provide a fully integrated system of care guided by values such as integrity, quality, service, and, of course, results. If you would like to work with an organization that gives you the tools, resources, and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente. For consideration, please forward your CV to: Bettina.X.Virtusio@kp.org or call Bettina at (800) 541-7946. We are an AAP/EEO employer. http://physiciancareers.kp.org/scal. [665] practice management

PRACTICE MANAGEMENT SERVICES/PRACTICE MANAGER/KEY STAFF JOB SEARCHES: Let the practice professionals find you the right person. Plus, you are not identified. We place the ads, receive the applications, interview the better candidates, do reference checking and bring you the best 2 to 4 candidates for final interviewing. We also do the salary and benefits negotiation with the preferred candidate. We know the medical office and can pinpoint what you need. Reasonable fees. Contact Regina Reading or George Conomikes of Conomikes Associates, Inc.; (858) 720-0379 or email rreading@conomikes.com.

NONPHYSICIAN POSITIONS AVAILABLE MEDICAL ASSISTANT/BACK OFFICE: Busy OB/GYN practice needs experienced MA to start 08/09. Competitive wage and benefits. Spanish a plus but not required. Fax resume to (619) 2984250. [673] PART-TIME PA OR NP: Small family practice in Chula Vista, two blocks north of Scripps Chula Vista Hospital, is seeking a bilingual PA or NP for part-time employment. Please call Drs. Jenkin or Tetteh if interested at (619) 804-7252. [669] REGISTERED NURSE (RN): Family medicine office in Torrey Hills seeking a full-time, experienced RN. Previous clinical experience required. Salary and benefits are negotiable. Please call (858) 350-8100 or email résumé to admin@torreyhillsfamilymedicine.com. [577] PART-TIME MEDICAL ASSISTANT/BACK OFFICE: Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit résumés via email to dlpotter22@hotmail.com. [576] PHYSICIAN POSITIONS WANTED

PRACTICES FOR SALE

MEDICAL EQUIPMENT

DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185]

FAMILY PRACTICE FOR SALE: • S olo practice with associate • W ell established 20 years, strong • • • • • •

patient base 900K yearly gross, no HMO Very upscale location Currently no nights, weekend call or hospitalizations Beautiful office fully equipped Moderate complexity lab, new digital Xray Slit lamp, Spirometry, computer read ECG Call Peter Graham, Broker 858-395-9928 Call Sally at 858-736-5818

SMARTSOUND ULTRASOUND MACHINE: For cellulite treatment, deep tissue massage, and muscle pain — and promotes post-operative healing: $3,950. Item originally purchased for $15,000. Machine is like new, was placed in storage shortly after purchase, and in perfect working condition. Willing to negotiate price. Please call (858) 693-3000 for more information. [695] MEDICAL EQUIPMENT FOR SALE: Contour operating table, plastic surgery components, now Dexta surgical. Perfect for oral surgery, plastic surgery, ENT dermatology. Built in mayo stands, monitor brackets, equipment brackets, power foot controls, arm boards, head rest, Burton surgical light, heavy duty casters, table lock, auto trendelenberg, dual back rest position controls, articulating back. A mobile operating room! Contact Keith Wahl, MD, at kwahl@san.rr.com or on cellular at (858) 518-2190. [681]

MD SEEKING PART-TIME EMPLOYMENT: Elderly MD in North San Diego with prior legal, weight, etc., experience seeking part-time employment. Call (949) 492-0198. [651]

“

Place your advertisement here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

When times are good, you should advertise. When times are bad, you MUST advertise.*

”

Advertise in the San Diego County Medical Society 2010 Pictorial Membership Directory

The SDCMS Pictorial Membership Directory is published annually and mailed to all member physicians (approximately 3,000). It is also available for purchase by non-member physicians and other interested parties. Advertising in the SDCMS Pictorial Membership Directory is a cost-effective and profitable way to get referrals and put your message in front of physicians, office staff, and patients who utilize this critical resource on a daily basis.

SDCMS Member Physicians Receive

25% off

a d v e r t i s i n g r at e s

Color advertisements and premium positions are limited and available on a first-come, first-served basis. Contact Dari Pebdani today: 858-231-1231 or DPebdani@SDCMS.org *From an article by American Business Media entitled “Making a Recession Work for You.”

A p r i l

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Hero for a Day By Richard A. Brown, MD

Boy Slices His Wrist on His Snowboard Five Hours Later …

he phone rang. I ignored it. It beeped a message. I ignored it. I do not fiddle with my phone on a ski lift. I figure that either the phone or I will fall off. I knew what the call was about anyway. Dinner that night. Ten minutes later the ringer sounded again. I no longer had a choice. I had to answer. It was not about dinner. Not even close. Given that I was not on call, I was not ex-

pecting to speak to someone in the ER. On the other end, a surgeon I know was telling me that a 14-year-old had sliced his wrist on his snowboard. His fingers had no function and no blood supply. Would I please come in and help? I was supposed to be on vacation — not working. Clearly, I was going to do the case. To decide otherwise would have violated who I think I am. I am not going to lie. I had no desire on Earth to tackle the problem. I knew time was critical and that I would have to push. I got an ambulance to pick me up at the mountain and drive me to the hospital. As I walked to the OR, I was playing the usual mental games. Sometimes things aren’t as bad as described. This one was: 11 tendons, both major nerves, and both major arteries. Five hours later, the task was complet-

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ed. Everything was fixed. Blood was again flowing. I was relieved and tired. Outsiders assume that everything will always work out. I know better. I was already trying to figure out what I would do if I got a call the next day telling me that the arteries were clotted. Paranoia defines me. No such call occurred. Instead I had three people phone me to sincerely thank me for operating on the boy. I had three other people give me real hugs. The response was unexpected and overwhelmingly gratifying. Medicine is a complicated, perplexing, and at times profoundly frustrating profession. Worth it? Absolutely.

the A u t ho r : Dr. Brown, SDCMS and CMA member since 1993, is board certified in both surgery of the hand and orthopedic surgery. He is a member of Torrey Pines Orthopaedic Medical Group, Inc.

About

Submit your “Hero for a Day” stories for possible publication to Editor@SDCMS.org.

Superior Standards.

“

From the business structure of this physcian owned and governed company, to the proactive approach to risk management, CAP’s priorities are consistent with my own style of practice and business philosophies.

“

– Tammy Wu, MD CAP District Council Member

The Cooperative of American Physicians, Inc. (CAP)

is the only physician owned and governed company whose

core product, Mutual Protection Trust, is Rated A+ (Superior) by A.M. Best Company. Superior physicians are dedicated to excellence. They should expect nothing less from their medical professional liability provider.

For more than 30 years, CAP has rewarded the dedication of superior physicians with superior protection for less. We keep our costs low by keeping our standards high. Membership might not come easy,

but once you get in, you know you’re in good company. To find out more, call 800-252-7706, or visit www.superiorphysicians.com.

C ooperative

SAN DIEGO

a meriCan p hysiCians , i nC . | 333 s. h ope s t ., 8 th f loor | l os a ngeles , Ca 90071 |

ORANGE

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The Mutual Protection Trust (MPT) is an unincorporated interindemnity arrangement among physicians authorized by Section 1280.7 of the California Insurance Code. Members do not pay insurance premiums. Instead, they pay tax-deductible assessments, based on risk classifications, for the amount necessary to pay claims and administrative costs. No assurance can be given as to the amount or frequency of assessments. Members also make a tax-deductible Initial Trust Deposit, which is refundable according to the terms of the MPT Agreement.

$5.95 | www.SANDIEGOPHYSICIAN.org PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

Does Your Insurance Company Have the Strength to Endure?

Strength and flexibility. That’s what your practice needs to thrive during challenging economic times. NORCAL Mutual Insurance Company has received an “A” (Excellent) financial rating from A.M. Best, the leading provider of insurance industry ratings, for the past quarter century. Our financial stability has allowed us to return more than $372 million in dividends to our policyholders. Visit www.norcalmutual.com today, or call 800.652.1051.

Our passion protects your practice.