October 2010 by San Diego Physician

✖ SDCMS Celebrates Its 140th Anniversary in 2010 ✖ Reaching 8,500 Physicians Every Month

october 2010

official publication of the san diego county medical society

Infectious

Disease Stopping the Dominos From Falling

“Physicians United For A Healthy San Diego”

CyberGuard

INFORMATION PRIVACY BREACH, ELECTRONIC DATA RECOVERY, AND REGULATORY PROTECTION

Are you ready for the fastest growing threat to your medical practice? Members of The Doctors Company are.

Privacy and data security exposure is the fastest growing threat to medical practices today. In response, The Doctors Company is proud to introduce CyberGuard cyber liability protection. We are the first medical liability insurer to include this important benefit as part of our core coverage. Our members receive this protection automatically. Shouldn’t you? To learn more about our medical professional liability program and CyberGuard, call (800) 328-8831, extension 4390 or visit www.thedoctors.com/cyberguard.

Endorsed by

www.thedoctors.com

S A N D I E G O P HY S I CI A N .or g october 2010

october 2010 SAN DIEGO P HY SIC I A N. o rg

thismonth Volume 97, Number 10

features Infectious Diseases

12 Mandatory Healthcare Personnel Influenza Immunization: The Time Has Come by Mark Sawyer, MD 18 2010 Healthcare Associated Infections Program: Legislative Update by Frank Meyers and Kim M. Delahanty

22 Hiv Testing: Recommended As Part of

Routine Patient Care by James Marx

24 Antibiotic Use in Animals: A Concerning Situation in Need of Resolution by Norman J. Waecker Jr., MD, MPH

26 What’s All the Whoop About? Resurgence of Pertussis in California by Robert E. Peters, PhD, MD

MD (A: Venu Prabaker, MD) Hillcrest Niren Angle, MD, Steven A. Ornish, MD Kearny Mesa John G. Lane, MD (A: Jason P. Lujan, MD) La Jolla J. Steven Poceta, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Doug Fenton, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD)

Alternate Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD Alternate Retired Physician Director Mitsuo Tomita, MD Medical Student Director Adi J. Price CMA Speaker of the House James T. Hay, MD

ex-officio, nonvoting board members

34 Physician Marketplace

dation sdcmsfoun

CMA Past Presidents Robert E. Hertzka, MD, Ralph R. Ocampo, MD CMA district I Trustees Theodore M. Mazer, MD, Albert Ray, MD,

Robert E. Wailes, MD CMA Trustee (other) Catherine D. Moore, MD, CMA Solo and Small-group Practice Forum Delegates

Michael T. Couris, MD, James W. Ochi, MD Alternate CMA Solo and Small-group Practice

go e i D n a S s s e Project Acc

By Paul Neus

tein, MD

Forum Delegate Dan I. Giurgiu, MD

AMA Delegates James T. Hay, MD, Robert E. Hertzka, MD Alternate AMA Delegates Lisa S. Miller, MD, Albert Ray, MD

go County eer in San Die nt u ol V to s hysician ortunity for P A Unique Opp family. care for her

s rebetter able to years old, wa goals alilia P., 34by authors en own and not necessarOpinions are betheir plained the Patient An expressed had already ce. They ex ic. ShePhysician ily those of San orcuSDCMS. San Diego Physician et in my offi al colDiego ite straightlus, qu me ren re for cal n we al cia red ich fer go Physi m, wh e mmallren Die gra tur reserves the right to edit contributions for clarity and length as 11 uc pro an San str th the gh the of th d wi g throu pain hadNot responsible for unsodiagn le articles current well asose to reject any material submitted. impressed wi While leafin to pass. Re y designed ward. I was across multip ge e arl vefor lar cle pro s com e im too wa d I’v col y licited manuscripts. th Advertising wa by m, which short-live rates and information sent upon magazine, ts were request. to lunteerism in Diego Physician in no the ER wi of advertising of the progra in rSan mind. Patien medical vo contisent her Acceptance I first met he ctitioner in recounting -ap- way us when tured across - SDCMS of products or constitutes approval or endorsement s obvio with the pra al. Any pre uncomby e have ven ment. It wa remely prior to referr just beyond to s ext ed leagues. Som ne wa ed een go services advertised. San Diego Physician and SDCMS reserve the ect scr she ve to be ce that tion of uld be dir others ha d offi ora wo ile sse s lab the wh pre ion , col im est nts rejectain any advertising. Address all editorial communications ne th the wi to maxi- right to le. ment qu have been , I er int es the po ord Ag s, cas in all it nic In tab tofor Editor@SDCMS.org. All advertising alth Tro inquiries can be sent to DPebto the vis these phyHe or of d id the border. pri an avo sity ce C, to ero s, ACSan Diego Physician ck our offi ent was dani@SDCMS.org. is published monthly on the sm and gen d with sho Project Acces ncy. The int by the ideali sfully treate rates are $35.00 per year. For suband to first of thewa s succesSubscription mize efficie y referrals le for in-free. patient month. unnecessar sicians. nefit scriptions, is not feasib She is now pa email Editor@SDCMS.org. [San or- Diego County irrelevant or otripsy. htf ctitioner, it st likely to be aig lith ce pra mo str ve o cti nts as wa sol pra tie a As been se pa Society Printed in the U.S.A.] ination Medicalref e away from errals have (SDCMS) identify tho vioustion. Coord mit the tim Most manned cases. Ob al interven me to com ivities would , as well as aforementio from surgic lunteer act cedure is gery center upon, ward as the rapeutic pro by that such vo spital or sur the but not act ged ho or a er, an ic th nd rt arr ost wi po pa uld be left to vices ly, if a diagn tment on the support, wo date. I was indiring my ser time commi anesthesia ends ices, when y of voluntee indicated, the the staff, ext s. Medical dev the possibilit s compa, as well as Project Acces ion. ful way. Dr. ted by variou the clinician m na of fro do tial consultat l be ini nt cal in a meaning te eived a ed, would new patie immedia te, rec cat I for cre the y ule d dis e da ed e on of Sh bey Then on siologist. gested sch resolution he sug e est the . Th an in s. nth an is renie r mo nson, However, it ms where the e patient pe community Rosemarie Joh 39-year-old eatable proble e nsults was on he medical

36 S A N D I E G O P HY S I CI A N .or g october 2010

geographic and geographic alternate Directors East County William T. Tseng, MD, Heywood “Woody” Zeidman,

Resident Physician Director Katherine M. Whipple, MD

Classifieds

Secretary (SDCMS At-large Director) Robert E. Peters, PhD, MD

Alternate Young Physician Director Kimberly M. Lovett, MD

10 The Doctors Company and Its Tribute Plan: Enhancing the Benefits of Membership!

Navigate the HIT Adoption Process and Optimize Your Ability to Obtain Federal Subsidies

Treasurer Sherry L. Franklin, MD

Young Physician Director Van L. Cheng, MD

6 Briefly Noted SDCMS Medical Office Manager Bulletin Board, and More …

• HIT Update

President-elect (CMA District 1 Trustee) Robert E. Wailes, MD

Communications Chair Theodore M. Mazer, MD

4 Community Healthcare Calendar

sdcms.org exclusive

Past President (AMA Alternate Delegate) Lisa S. Miller, MD

other board members

4 SDCMS Seminars, Webinars and Events

by Paul Neustein, MD

SDCMS Board of Directors Officers President Susan Kaweski, MD

At-large and At-large alternate Directors Jeffrey O. Leach, MD, Bing S. Pao, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD, Mihir Y. Parikh, MD (A: Carol L. Young, MD (sdcms foundation president), Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Alan A. Schoengold, MD)

departments

36 Project Access San Diego: A Unique Physician Volunteer Opportunity

Managing Editor Kyle Lewis Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, MD, PhD, David M. Priver, MD, Roderick C. Rapier, MD Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Project Designer Lisa Williams Copy Editor Adam Elder

POWERFUL. CONFORMAL. FAST. THAT’S HOW CANCER TREATMENT SHOULD BE. At San Diego Radiosurgery, we offer treatment using the Novalis Tx platform for image-guided radiosurgery. Novalis Tx incorporates advanced imaging, treatment planning, and treatment delivery technologies from Varian Medical Systems and BrainLAB, enabling fast, highly precise, non-invasive radiosurgery treatments for cancers and other conditions in the brain, head, neck and body. The 2.5 mm HD 120 high-definition beam shaper of the Novalis Tx offers the smallest leaves available for highly precise conformality around the tumor. Tighter margins can result in superior dose escalation to the tumor, while reducing the risk of complications. Call or visit our website for more information. Palomar Medical Center Department of Radiation Oncology 555 East Valley Parkway | Escondido, CA 92025 760-739-3835 / SDRadiosurgery.com

San Diego Radiosurgery is a service of Palomar Medical Center.

october 2010 SAN DIEGO P HY SIC I A N. o rg

calendar

sdcms Seminars / Webinars / Events Free to member physicians and their staff. For further information, contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.org, or visit SDCMS.org. “Certified Medical Coder” Course (seminar) 5 Fridays, Oct. 1–29, 8:00am–4:00pm “Strategies for Economic Survival” (seminar/webinar) Thurs., Oct. 7, 11:30am–1:00pm “Expert Witness, Medical Board Interactions” (legal issues seminar/webinar) Thurs., Nov. 4, 11:30am–1:00pm “Physician Leader’s Toolbox” (seminar) Fri.–Sat., Nov. 12–13, 8:00am–4:00pm “Emerging Patient Safety Issues Impacting Office Practices” (risk management webinar) Wed., Nov. 17, 6:30pm–7:30pm

community Healthcare Calendar 5th Annual Frontiers of Clinical Investigation Symposium: Pain 2010 Bench to Bedside Oct. 14–16 • Estancia La Jolla • cme.ucsd.edu/b2b2010

“Integrating the Medical, Ethical, and Philosophical Aspects of End-of-life Care” Nov. 6 • 8:00am–3:00pm • Paradise Point Resort and Spa, San Diego • (800) 827-4277

Challenges in the Perioperative Management of OSA Patients Oct. 15 • Location TBD • cme.ucsd.edu

Sharp Grossmont Hospital Vascular Conference 2010: “Advancing Awareness, Prevention and Treatment of Vascular Disease” Nov. 6 • Hard Rock Hotel, San Diego • (619) 740-4550, shelley.berthiaume@sharp.com

The Complete Scope of Cosmetic Surgery (CACS 11th Annual Meeting) Oct. 15–17 • Hard Rock Hotel, San Diego • 17 Hours CME • calcosmeticsurgery.org Meeting of the San Diego Chapter of Physicians for a National Health Plan Oct. 16 • 10:00am • 5644 Soledad Road, La Jolla • pfriedman@ucsd.edu “Is Legalizing Marijuana Ethical? A Discussion of California’s Proposition 19” Oct. 21 • 7:00pm • Hilton San Diego Bayfront Hotel • mitsuo@cox.net

“Emerging Patient Safety Issues Impacting Office Practices” (risk management webinar) Thurs., Nov. 18, 11:30am–12:30pm

American Society for Bioethics and Humanities 12th Annual Meeting Oct. 21–24 • Hilton San Diego Bayfront Hotel • asbh.org

“Preparing to Practice” Workshop (seminar) Sat., Nov. 20, 8:00am–4:00pm

Cutting Edge Strategies in Diabetes Care: Making the Connection Oct. 30 • San Diego Convention Center • cme.ucsd.edu

4th Annual UCSD Hands-on NOTES and Single Site Surgery Symposium Nov. 11–13 • Omni San Diego Hotel • cme.ucsd.edu/notes West Coast Geriatric Psychiatry Conference Feb. 16–19, 2011 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu Topics and Advances in Internal Medicine Mar. 7–13, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu Topics and Advances in Pulmonary and Critical Care Medicine Mar. 13–14, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

To submit a physician-focused, San Diego County healthcare event for possible publication, email KLewis@SDCMS.org.

S A N D I E G O P HY S I CI A N .or g october 2010

brieflynoted

SDCMS Medical Office Manager By Sonia Gonzales, Your Office Manager Advocate Sdcms’ Second-Annual

g Medical “Outstandin Office Manager” ! Contest Is Now Under Way

can nominate their office SDCMS member physicians writing (up to 600 words) managers by explaining in the best in San Diego why their office manager is eive a brand-new iPod County. The winner will rec d recognition as San Diego Touch, a $250 gift card, an al Office Manager for County’s Outstanding Medic be sent to SDCMS, Attn.: 2010! Nominations should Road, Suite 250, San Sonia Gonzales, 5575 Ruffin d to SGonzales@SDCMS. Diego, CA 92123, or emaile nners will be announced in org by October 15, 2010. Wi Diego Physician. the December issue of San

Don't See the FA You Want on this P Qs age?

Email your “O Bulletin Board ffice Manager ” SGonzales@Squestions to DCMS.org.

S A N D I E G O P HY S I CI A N .or g october 2010

Extra Special Focu s

As an office manager, o ne of your p rimary resp sibilities is onfinding goo d deals, an d I’m abou give you in t to formation o n how you can take ad tage of a gre vanat deal: “Co nnect the D ocs” from SD CMS and C MA. Your docto r(s) may no t know this , but they ca get either th n eir next ye ar’s member half-price (i ship dues at f they are members an d paying fu dues) or a fr ee SDCMSll CMA mem bership for following ye the ar. With “C onnect the physicians Docs,” you will be able r to support th and support eir colleagu es medicine at the same tim new memb e. With each ership, SDC MS-CMA g rows stronge and member r ship has even greater rewar All your do d s. ctors have to do is talk leagues wh to their colo have nev er been mem courage th b er s and enem to sup port an org anization th fights for ph at ysicians an d patients in nationally. o u r st at e and Members en joy a wide ra nge of benefi from insura ts nce savings to expert le tice manag gal and pra ement supp cort. For recr uitment cred please conta it, ct Janet Lo cket, SDCM member dev S director of elopment, at Jlockett@SD at (858) 300 CMS.org or -2778.

fice Ask Your Ofo cate! v d A r e g a n a M

Question: Answer:

n? th expired medicatio What should I do wi

Enforcement Agency According to the Drug ication to the pharnnot return the med (DEA), if the office ca armaceutical dit, it can call EXP Ph cre for ny pa m co al maceutic in California) at (800) (the only distributor Services Corporation properly. s and dispose of them ug dr e th ke ta to 97 350-03 directions on how the medication with EXP will mail a box for even small y does not matter, so tit an qu e Th . ck ba it to ship ation, visit EXP’s ed. For further inform packages are accept com website at expworld.

Become A Certifired Medical Code

In Five Days!

coder course Our next certified medical tinues on starts Oct. 1, 2010, and con th nd th (five Fridays). the 8th, 15 , 22 , and 29 d end at 4 Classes began at 8 a.m. an tification exam p.m. each day with the cer ). Cost of the on the final Friday (Oct. 29 ns and their course — member physicia , which includes staff discounted rate: $599 the certification exam.

Question: Answer:

Do we have to provide hepatitis B vaccinations for all the staff?

Employers must offer the HBV vac cine to all employees with occupational exposu re to blood and other potentially infectious material (OPIM), following training and within 10 working days of initial assignment to work duties. You must offer a free post-exposure evaluation and follow-up to employees who have an exposure incident, at no “out-of-pocket” expense and at a reasonable time and plac e, and you must ensure a licensed physician or other license d healthcare professional supervises the vaccination. Employ ers may not require employees to use health insurance to pay for the series. You must allow employees who initially decline the vaccine to have the vaccine later if they wish; and all laboratory tests must be conducted by an accredited laboratory and at no cost to the employee. Employers need not provide the hepatitis B vaccine to employees following training or ass ignment to new job duties if the employee: • has already received the vaccine ; • has immunity based on antibod y testing (although such testing cannot be made mandatory for employees); or • has medical contraindications to the vaccine. Employers are required to docum ent the conditions exempting the employee in the employee’s confidential medical record, and must also obtain a signed dec lination form from employees who do not wish to have the vac cine. There are exemptions, but CMA recommends that employers simply offer HBV vaccine to all employees, including first-aid providers, who may be exposed to blood and OPIM.

october 2010 SAN DIEGO P HY SIC I A N. o rg

brieflynoted

! d e c i t o N t e G s n ia P hysic py Birthday! ap H a rs to la is g e L r ou Y h Wis

d that you vote by you’re paying attention an t tha w kno s tor isla leg r Physicians: Let you cedures for government TE: Due to mail handling pro NO ay! thd bir py hap a m several weeks wishing the , offices may be delayed by DC , ton ng shi Wa to il ma l office buildings, posta or email if possible. or even months. Please fax 7 Birthday: November 3 r tobe ri Saldana Oc : Lo er mb Birthday State Assemblyme Kehoe e tin ris embly.ca.gov Ch ass tor a@ na dan Se .sal te Sta E:assemblymember .gov E: senator.kehoe@sen.ca Capitol Office: 0 State Capitol, Room 505 14 958 CA Sacramento, 6) 327-2188 T: (916) 651-4039 F: (91 San Diego Office: 2445 Fifth Ave., Suite 200 San Diego, CA 92101 9) 645-3144 T: (619) 645-3133 F: (61

Birthday: October 27 land State Senator Mark Wy

ca.gov E: senator.wyland@sen. Capitol Office: 8 State Capitol, Room 404 14 958 CA o, Sacrament 6) 446-7382 T: (916) 651-4038 F: (91 Carlsbad Office: y, #105 1910 Palomar Point Wa Carlsbad, CA 92008 0) 931-2477 T: (760) 931-2455 F: (76

1 Birthday: November ll Issa rre Da ive U.S. Representat

v/issa E: (via website) house.go ce: Capitol Offi 2) 225-3303 T: (202) 225-3906 F: (20 District Office: #310 1800 Thibodo Rd., Ste. Vista, CA 92081 0) 599-1178 T: (760) 599-5000 F: (76

S A N D I E G O P HY S I CI A N .or g october 2010

Capitol Office: bly California State Assem 849 P.O. Box 942 0076 Sacramento, CA 94249319-2176 6) (91 F: 76 -20 319 6) T: (91 San Diego Office: 1557 Columbia St. San Diego, CA 92101 9) 645-3094 T: (619) 645-3090 F: (61

11 Birthday: November xer Bo ra rba Ba U.S. Senator

te.gov E: (via website) boxer.sena ce: Capitol Offi 2) 228-2382 T: (202) 224-3553 F: (20 San Diego Office: 600 B St., Ste. 2240 San Diego, CA 92101 2) 228-3863 T: (619) 239-3884 F: (20

you take care of the san diego communit y ’s health. we take care of san diego’s

healthcare communit y.

Get in

touch

3 Income Tax Planning 3 Wealth Management

Your SDCMS and SDCMSF Support Teams Are Here to Help!

3 Employee Benefit Plans 3 Profitability Reviews

SDCMS Contact Information 5575 Ruffin Road, Suite 250 San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO/Executive Director Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO/CFO James Beaubeaux at (858) 300-2788 or Beaubeaux@SDCMS.org Director of Membership DevelopmenT Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org Director of Membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org director of medical office manager support and Office Manager Advocate Sonia Gonzales at (858) 300-2782 or SGonzales@ SDCMS.org Director of Engagement Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org Director of Communications and Marketing Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org BUSINESS MANAGER Nathalia Aryani at (858) 300-2789 or NAryani@SDCMS.org administrative assistant Betty Matthews at (858) 565-8888 or at BMatthews@SDCMS.org Letters to the Editor Editor@SDCMS.org General Suggestions SuggestionBox@SDCMS.org

3 Outsourced Professional Services (CFO, Controller) 3 Organizational and Compensation Structure 3 Succession Planning 3 Practice Valuations 3 Internal Control Review and Risk Assessment

akt A KT LLP, CPAs and BUSINESS CONSU LTANTS CARL SBAD

ESCONDIDO

760-431-8440

S A N DIEGO

W W W.AKTCPA.COM

RMITCHELL@AKTCPA.COM

ron mitchell, cpa director of health services

SDCMSF Contact Information 5575 Ruffin Road, Suite 250 San Diego, CA 92123 T (858) 565-8888 F (858) 560-0179 W SDCMSF.org Executive Director Kitty Bailey at (858) 300-2780 or KBailey@SDCMS.org project access PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or at BSalcedo@SDCMS.org Healthcare Access Manager Lauren Radano at (858) 565-7930 or at LRadano@SDCMS.org Patient Care Manager Anhel Reyes at (858) 565-8156 or at Anhel.Reyes@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or at Rebecca.Valenzuela@SDCMS.org

S ITS 140 CELEBRATE � SDCMS

0� ARY IN 201 ANNIVERS y Month Physicians Ever Reaching 8,500

ATION OFFICIAL PUBLIC

OF THE SAN

DIEGO COUNTY

Y MEDICAL SOCIET

10 M AY 20

IOR SESN UNAMI The

NS UNITED “PHYSICIA

DIEGO” LTHY SAN FOR A HEA

25%

SDCMS member physicians receive

off

advertising in this publication.

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

october 2010 SAN DIEGO P HY SIC I A N. o rg

sdcmsmemberbenefits By The Doctors Company

The Doctors Company and Its Tribute Plan Enhancing the Benefits of Membership!

What Is the Tribute Plan? The Doctors Company has paid out more than $1.7 million in Tribute Plan awards to retiring doctors for their dedication to the practice of good medicine. Launched in 2007, the Tribute Plan is our way to reward physicians for their loyalty to The Doctors Company and commitment to superior patient care. To prove this commitment, The Doctors Company has created a plan that financially rewards physicians who dedicate themselves to superior patient care and keeping claims low. This year, The Doctors Company has enhanced the Tribute Plan Funding for the next three years. This means that in just six years, members will have accumulated approximately one year’s premium in their Tribute accounts.

The San Diego County Medical Society has exclusively endorsed The Doctors Company’s medical liability insurance program since 2005, with qualified SDCMS members receiving a 5 percent premium discount. Recently, The Doctors Company enhanced its Tribute Plan to further benefit SDCMS members.

Enhancement Period

30%

Base Funding

percentage of premium

29%

Enhanced Funding

25% 24%

20% 15%

14%

10% 10%

10%

2007

2008

2009

10%

2013

2014

2015

2016

5% 0%

2010

2011

2012

Here are some examples*:

Ten-year projections: For members who have been with The Doctors Company since 2007: Annual premium

Base Funding Tribute balance at end of 2016

Enhanced Funding Tribute balance at end of 2016

For doctors joining The Doctors Company in 2010: Annual premium

Enhanced Funding Tribute balance at end of 2019

$15,000

$13,000

$21,000

$15,000

$12,000

$21,000

$35,000

$30,000

$49,000

$35,000

$28,000

$48,000

$70,000

$61,000

$98,000

$70,000

$56,000

$96,000

*Projections are not intended to be a forecast of future events or a guarantee of future balance amounts.

Base Funding Tribute balance at end of 2019

S AN D I E G O P HY S I CI A N . or g october 2010

How do physicians enroll in the Tribute Plan? All members of The Doctors Company are immediately eligible and are enrolled.

Support for Life.

How do physicians qualify for a Tribute Plan Award? A member of The Doctors Company must simply reach age 55 or older, retire permanently from medicine, and be insured by The Doctors Company for five continuous years or more on the day they retire. Why the Tribute Plan benefit? The Tribute Plan is a benefit that was born out of The Doctors Company’s tenacious desire to uphold its founding mission as an organization created by doctors to advance and protect the practice of good medicine. It’s a financial benefit that The Doctors Company has created in an effort to provide tangible proof that it is accountable to the physicians we insure. It helps them reinforce the fact that, as a physician-founded/owned/led organization, they consider the physicians they insure to be members of our organization and not merely policyholders. And it proves they are dedicated to rewarding our members — unlike commercial insurance companies that view doctors as anonymous policyholders.

To find out more about this SDCMS member benefit, visit thedoctors.com/ tribute. {Abou t th e Au thor} SDCMS-endorsed The Doctors Company is the largest national insurer of physician and surgeon medical liability in the United States, with 45,000 member physicians, $2.8 billion in assets, more than $1 billion in surplus, an A rating by Fitch Ratings, and an A- rating by A.M. Best Company.

Refurbished & New Medical Equipment ,i«> ÀÃÊUÊ > LÀ>Ì ÊEÊ*ÀiÛi Ì ÛiÊ > Ìi > ViÊUÊ,i Ì> Ã -iÀÛ }Ê-> Ê i} Êv ÀÊ ÛiÀÊÎäÊ9i>ÀÃ Equipment & Support for All Specialties

877-583-5130 www.akwmedical.com/sdcms

Visit our Showroom - 5620 Kearny Mesa Rd. #A, San Diego

SDCMS Tweets! Follow SDCMS on Twitter.com to keep abreast of H1N1 updates, the latest healthcare reform developments, SDCMS seminars, and more!

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases

Mandatory Healthcare Personnel Influenza Immunization T he T ime Has C ome By Mark Sawyer, MD

S AN D I E G O P HY S I CI A N . or g october 2010

Many healthcare organizations across the country have implemented mandatory healthcare personnel (HCP) influenza immunization policies in the past two years. The reasons are obvious: 1. Influenza is a ubiquitous, serious disease. The impact of influenza can be illustrated most graphically by the estimated 36,000 deaths that are attributed to this infection every year in the United States. 2. Influenza is very contagious. Think about the speed with which the 2009 H1N1 influenza pandemic developed and spread around the world. The H1N1 pandemic also demonstrated that people who are not immune to influenza as a result of immunization or prior infection are completely vulnerable. Especially vulnerable are the very young and the very old, who either can’t be immunized or who do not respond well to immunization. Of the 36,000 annual deaths from influenza 90 percent are people over 65 years of age. 3. Vulnerable patients are in regular contact with HCP in both outpatient and inpatient facilities. Unfortunately, these same HCP, who are there to help people manage their health, are responsible for infecting them with influenza. Why does this happen? • Influenza can be transmitted before people have symptoms of illness. • HCP continue to work despite being ill. • HCP are not compliant enough with infection control measures to limit transmission of infections from them to their patients. • 20–50 percent of HCP are not protected from influenza infection because they refuse to be immunized. The role that HCP play in transmitting influenza to patients and the failure to immunize HCP is a major patient and staff safety issue that needs to be addressed in both inpatient and outpatient healthcare settings. In addition to the staff and patient implications of HCP influenza immunization, California law now requires that all hospitals submit influenza vaccine coverage rates/declination rates for their HCP, and these rates will be publically reported and listed by hospital beginning in the fall of 2010. Note: Visit SDCMS.org to access this article’s references.

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases For the purposes of this paper, healthcare personnel are defined as all persons whose occupational activities involve contact with patients or contaminated material in a healthcare, home healthcare, or clinical laboratory setting. Healthcare personnel are engaged in a range of occupations, many of which include patient contact even though they do not involve direct provision of patient care, such as dietary and housekeeping services. The guidance contained in this paper applies to healthcare personnel working in the following settings: acute care hospitals, nursing homes, skilled nursing facilities, physicians’ offices, urgent care centers, outpatient clinics, and home healthcare agencies. It also includes those working in clinical settings within non-healthcare institutions, such as school nurses or personnel staffing clinics in correctional facilities. The term “healthcare personnel” includes not only employees of the organization or agency, but also contractors, clinicians, volunteers, students, trainees, clergy, and others who may come in contact with patients.

Influenza Vaccine Influenza vaccine has been used for decades in the United States and has an excellent safety record. There are now two forms of vaccine: an injectable vaccine and a live, attenuated vaccine that is given intranasally. Both are very effective at preventing influenza in the majority of people immunized. Important vaccine characteristics include: • The vaccine is most effective in younger, healthier individuals. The very young, the elderly, and immunocompromised persons of all ages may not be protected even if immunized. This makes it essential that persons who come in contact

"T he vaccine gave me the f lu."

with these groups be immunized. • Influenza vaccination of HCP decreases mortality in the patients they care for. • Influenza vaccination of HCP decreases absentee rates. • Influenza vaccination has been recommended for all HCP by the Healthcare Infection Control Practices Advisory Committee (HICPAC) and Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) since 1986. • Despite this longstanding recommendation and extensive efforts to provide education and free, convenient vaccine to HCP, only 61.9 percent received seasonal influenza vaccine in 2009–10, and only 34.7 percent received both seasonal vaccine and the unique monovalent H1N1 vaccine. Rates in recent years have been similarly disappointing, with overall influenza coverage among HCP never exceeding 49 percent. • Joint Commission Standard IC.02.04.01 states that: The organization offers vaccination against influenza to licensed independent practitioners and staff. Among the standards for evaluation is, “The hospital takes steps to increase influenza immunization rates among their HCP.”

San Diego Experience The San Diego Hospital Influenza Immunization Partnership (SDHIIP) was formed in 2007 as part of a CDC project to improve influenza immunization rates among hospital-based HCP in San Diego. Participants included the County of San Diego Health and Human Services Agency (HHSA) Immunization Branch and all of the major hospitals in the region, including Rady Chil-

"I don't believe in vaccines."

S AN D I E G O P HY S I CI A N . or g october 2010

"I am not at risk for getting the f lu."

"I am not a risk to patients."

dren’s Hospital, Kaiser Permanente, Naval Medical Center San Diego, Palomar-Pomerado Health System, Scripps hospital network, Sharp hospital network, UCSD Medical Center, and Tri-City Medical Center. SDHIIP hospitals conducted extensive programs to promote HCP immunization within San Diego hospitals that included promotion, education regarding widely held myths associated with influenza vaccine, free and convenient access to influenza vaccine, implementation of declination statements as required by California law, and careful documentation of influenza vaccination rates. Despite such widespread efforts over a three-year period, HCP influenza immunization rates for San Diego County remain plateaued at approximately 60 percent. Voluntary programs have not achieved the levels of influenza vaccine coverage needed to protect patients and HCP.

Reasons Why HCP Don’t Get Vaccinated Unfortunately, HCP cite the same myths about influenza and influenza vaccine as the general public when asked why they are not seeking immunization. We hear time and again, “The vaccine gave me the flu,” “I don’t believe in vaccines,” “I just hate shots,” “I am not at risk for getting the flu,” “I am not a risk to patients,” “I never have time to get my flu vaccine.” Published studies document that these invalid and inaccurate perceptions are common among HCP. The SDHIIP project also conducted surveys of unimmunized HCP in San Diego and found very similar results. Almost none of the reasons cited by HCP for failing to get immunized are valid.

Mandatory Programs for HCP Influenza Immunization Due to the ongoing problems of high influenza infection rates and low HCP immunization rates, coupled with failure of voluntary programs to achieve adequate levels of HCP immunization, many hospitals and organizations have implemented mandatory HCP influenza immunization programs. Mandatory HCP immunization has now been endorsed by the Infectious Disease Society of America, the Association for Professionals in Infection Control (APIC), and the National Patient Safety Foundation. Such programs have already been implemented in many hospitals in the United States. The first major mandatory program was implemented in 2005 at Virginia Mason Hospital system in Seattle. This organization went from HCP influenza immunization rates of less than 50 percent to rates of greater than 98 percent that have been sustained for four years now. BJC Healthcare system in St. Louis implemented a mandatory program in 2008. The BJC system has 26,000 employees, 11 acute care hospitals, and three extended care facilities. During the 2008–09 influenza season, 25,561 (98.4 percent) of 25,980 employees were vaccinated. The maximal influenza vaccine coverage achieved prior to that using a voluntary program was 71 percent. It can be done! During the 2009–10 influenza season, more than 40 hospitals/hospital systems have implemented mandatory HCP influenza immunization programs (immunize. org/hcw). In San Diego, Rady Children’s Hospital implemented a full policy and, similar to the outcomes at the Virginia Ma-

son and BJC systems, achieved a 98 percent immunization coverage rate. Naval Medical Center San Diego implemented a policy but it could not be completely enforced because of vaccine supply problems. Despite the shortage of vaccine, it was able to achieve a 91 percent coverage rate, compared to a rate of only 50–60 percent in prior years. Other prominent hospitals/systems that implemented mandatory policies during the 2009-10 season include: • Department of Defense (for all civilian employees at all installations) • UC Davis Health System, Sacramento, Calif. • UC Irvine Healthcare, Orange, Calif. • University of Pennsylvania/Children’s Hospital of Pennsylvania • Johns Hopkins Health System, Baltimore • New York-Presbyterian Hospital, N.Y. • Emory Healthcare, Atlanta • Cook County Hospital, Chicago • Children’s Hospital Orange County

Arguments Against Mandatory Influenza Vaccination of Healthcare Personnel There are those opposed to mandatory influenza immunization programs. In general their arguments reflect concern over personal choice and seem to ignore the patient safety and public health problem that the longstanding failure of HCP to voluntarily immunize has created. Common objections raised include: 1. Argument: Employers can’t mandate vaccination of employees. Response: There are already existing mandates in nearly every hospital system for measles, mumps, rubella,

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases

and varicella vaccine. These programs are highly effective with nearly universal compliance. In addition, annual tuberculosis screening is mandated. The program at Virginia Mason has been in place since 2005 and has withstood legal challenge. Argument: Voluntary programs work. Response: There are no hospitals in San Diego that have achieved greater than 80 percent HCP immunization rate despite a focused effort over the past five years. Argument: Vaccination isn’t 100 percent effective, so even vaccinated HCP could spread infection. Response: No intervention is 100 percent effective. Hand hygiene isn’t 100 percent effective in preventing healthcare-associated infection. This is not a reason to avoid a very effective intervention and instead do nothing. Argument: The vaccine has sideeffects. Response: In the BJC Health system experience, 21 (0.08 percent)/25,561 reported side-effects. Most of these were sore arms. Argument: A mandatory policy will cause qualified staff to quit. Response: At Rady Children’s Hospital San Diego only three staff resigned as a result of the implementation of a mandatory policy. At BJC Health system (see below), 8/25,980 employees resigned or were fired as a result of a mandatory policy. Argument: Wearing a mask as an alternative to influenza vaccine will not protect HCP. Response: Several recent studies have demonstrated that masks prevent HCP infection.

"I just hate shots." 7. Argument: Some HCP are allergic to the vaccine or have had previous severe side-effects from influenza vaccine. Response: Allergy is rare. In the BJC experience, among 25,000 HCP, only 107 (0.4 percent) were shown to be allergic to vaccine. For such individuals and for those with documented severe sideeffects, medical exemptions to vaccine should be granted. 8. Argument: Some people have a religious objection to vaccine. Response: Few organized religions have such an objection. In the BJC system experience, 90 people were able to document a true religious objection. For those, a religious exemption was granted.

Legal Implications and History to Date Most administrators are concerned that implementing a mandatory HCP influenza immunization program will bring legal challenges, particularly from employee unions. Although it is true that such programs have been challenged legally, to date no program has been disallowed following legal proceedings. Although a legal standard has not yet

been firmly established, a common theme of the legal rulings issued to date is that mandatory programs need to be included in contracting discussions with employee unions, but that they can be implemented. The most common accommodation required as a result of some negotiations is that employees that refuse to be immunized be offered an alternative method to prevent them from becoming infected and transmitting infection to their patients. The most commonly used alternatives are: a) wearing a mask all day while at work during the influenza season to prevent infection and/or transmission; b) taking prophylactic antiviral medications during the influenza season; or c) reassignment to nonpatient care duties.

SDCMS GERM Commission Recommendation Based on the continued high rates of influenza infection annually and the failure of extensive efforts to implement voluntary programs for HCP influenza immunization, SDCMS’ GERM Commission recommends mandatory HCP influenza immunization policies be adopted by all healthcare providers, facilities, and organizations in San Diego County.

About the Author: Dr. Sawyer, SDCMS-CMA member since 2010, is professor of clinical pediatrics at the UC San Diego School of Medicine and sits on SDCMS’ GERM (Group to Eradicate Resistant Microorganisms) Commission.

"I never have time to get my f lu vaccine." 16

S AN D I E G O P HY S I CI A N . or g october 2010

ARE YOU READY FOR EHR? ARE YOU READY FOR EHR? CHMB – The Choice for EHR & Successful Adoption Improved with&CHMB—ranked the top CHMB business – The performance Choice forstarts EHR Successful among Adoption

providers in California for EHR Adoption & Implementation Services. Here’s Improved business performance starts with CHMB—ranked among the top why hundreds of physicians have selected CHMB for building and installing providers in California for EHR Adoption & Implementation Services. Here’s the Allscripts EHR application into their community practices: why hundreds of physicians have selected CHMB for building and installing the AllscriptsAND EHRLOCAL application into their community practices: NATIONAL EXPERTISE •NATIONAL Established footprint 1,000 community physicians and clinics statewide AND LOCALwith EXPERTISE

“CHMB has been our trusted partner for more than “business CHMB has been our trusted six years.partner It madeforperfect sense business more than that when It wemade decided to move six years. perfect sense forward with EHR in our practice, that when we decided to move we entrusted our implementation forward with EHR in our practice, of Allscripts to them as well. They we entrusted our implementation have been there for us of Allscripts to them asevery well. step They of the way!” have been there for us every step of the way!” ELIZABETH SILVERMAN, MD Partner ELIZABETH SILVERMAN, MD North County OB/GYN Medical Group Partner

North County OB/GYN Medical Group

Call today for your FREE EHR today Readiness Assessment! Call for your FREE EHR Readiness Assessment! Ron Anderson • 1.760.520.1340 Marianne Gregson • 1.760.520.1333 Ron Anderson • 1.760.520.1340 Geoff Doyle • 1.760.520.1343 Marianne Gregson • 1.760.520.1333 Geoff Doyle • 1.760.520.1343

• Experts whofootprint know the full1,000 story–community Hardware Selection Procurement, Established with physicians&and clinics statewide Network Configuration, Application Support • Experts who know the full story– Hardware Selection & Procurement, TARGETED SOLUTIONS Application Support Network Configuration, •TARGETED World Class Portfolio – Clinical and Business Solutions – Allscripts, Dell, SOLUTIONS Cox Business • World Class Portfolio – Clinical and Business Solutions – Allscripts, Dell, • Cox Flexible approach to drive efficiencies and meet diverse needs, from Business multi-specialty and specialty, to single provider, to multiple providers • Flexible approach to drive efficiencies and meet diverse needs, from • multi-specialty Innovative technology that delivers at provider, the speedtoyou need providers and specialty, to single multiple PROVEN RESULTS • Innovative technology that delivers at the speed you need

•PROVEN Real Utilization RESULTS– 95% of physicians are at Meaningful Use with CHMB EHR Services • Real Utilization – 95% of physicians are at Meaningful Use with CHMB • EHR Superior Support – 98% client satisfaction on CHMB Clinical & IT Services Services during implementation & on-going support • Superior Support – 98% client satisfaction on CHMB Clinical & IT Services • during Outstanding ROI – 97% physicians believe CHMB’s services met all implementation & of on-going support expectations, including cost, training, implementation, and application • Outstanding ROI – 97% of physicians believe CHMB’s services met all optimization expectations, including cost, training, implementation, and application Asoptimization your business partner, let us navigate your entire EHR project As your business partner, let us and create the right solution to fit navigate your entire EHR project your practice. Count on us to train and create the right solution to fit you to use the EHR at its optimal your practice. Count on us to train level. It’s time to trade up to you to use the EHR at its optimal EHR and discover level. It’s time to trade up to Meaningful Use with CHMB. EHR and discover Meaningful Use with CHMB.

San Diego County — 1121 East Washington Ave., Escondido, CA 92025 Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618 San Diego County — 1121 East Washington Ave., Escondido, CA 92025 760.520.1400 • 800.727.5662 • www.chmbsolutions.com Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618 760.520.1400 • 800.727.5662 • www.chmbsolutions.com

CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

october 2010 SAN DIEGO P HY SICIA N. o rg

CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

Infectious Diseases

2010 Healthcare Associated Infections Program Legislative Update By Frank Meyers and Kim M. Delahanty, RN, BSN, PHN, MBA, CIC

S AN D I E G O P HY S I CI A N . or g october 2010

Since the spring of 2009, the infection control regulations landscape in the United States and in California has changed dramatically, impacting most San Diego County physicians — with three areas having the greatest impact: 1) the continuing trend in public reporting both nationally and at the state level; 2) the Centers for Medicare and Medicaid Services’ new interest in infection control in ambulatory surgical centers; and 3) the new Cal-OSHA aerosol transmissible disease (ATD) standard. As a recap, the Healthcare Associated Infections (HAI) program was created with the passage of three pieces of legislation: SB 739, SB158, and SB1058, which were incorporated into the Health and Safety Code Sections 1288.45–1288.9. The legislation mandates that the California Department of Public Health (CDPH) implement a program for surveillance prevention of HAIs and require general acute care hospitals to report their implementation of specified section process measures and rate-specified HAIs to CDPH for posting on its website, along with current infection prevention and control information. The legislation specifies that incident rates of infections be posted and be adjusted for risks using a method that is consistent with National Healthcare Safety Network (NHSN) methodology or methodology that is recommended by the HAI Advisory Committee for that particular section. All of this factored into the changes instituted regarding the methods by which hospitals report data to CDPH starting April 1, 2010. The requirement for data reporting started in 2009, but California had no funding at that time for staff. In the absence of a program, the data submitted to CDPH was stored — it was not examined, evaluated, or analyzed. As of March 2010, the HAI program has sufficient epidemiology staff to begin the process of accessing and evaluating this data. The influenza vaccination data is the only data that CDPH is not logistically able to collect through NHSN at the time. There is a process being initiated at CDC to address that, but currently there is none, so this data has been collected through a standardized form since 2008. The results of the initial evaluation will be presented by the HAI Program’s epidemiology team.

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases As the year ends, physicians can be assured that prevention of healthcareassociated infections will continue to be a focus for payers, consumers, and regulators.

In review, here are the indicators being reported: • central line insertion practices (CLIP) • compliance with surgical antibiotic prophylaxis guidelines (SCIP) • compliance with receipt of influenza vaccination to include declination of both healthcare personnel and physicians • compliance with influenza vaccination of high-risk patients • healthcare-associated MRSA bloodstream infection • healthcare-associated VRE bloodstream infection • Clostridium difficile infection • central-line-associated bloodstream infection, facility-wide • There is also a requirement for all deep tissue and organ space surgical site infections for certain surgeries to be reported, but at this time the language in the law is problematic and does not allow for enforcement.

Trust A Common Sense approach to IT Trust us to be your Business Advisor Hardware + Software + Networks Security + Support + Maintenance Ofer Shimrat (858) 569-0300 www.soundoffcomputing.com

S AN D I E G O P HY S I CI A N . or g october 2010

CLIP data was collected starting in July 2008 by form; the NHSN module to collect that data had not been implemented. That module was implemented in January 2009, so that data has been submitted and stored in NHSN and will be analyzed in the future. SCIP data is collected by another body. The law originally says that facilities have to report all HAIs and asks for these to be reported at NHSN, which also asks about nonhealthcare-associated infections. Some of the information entered is classified based on the CDC definition, which is requiring facilities to report non-healthcare-associated infections and causing undue stress on already stretched resources in the infection prevention programs of GACH. Per CDPH, the only way to ensure consistency in respects to the laboratory test used is to have one method of reporting, and the only one that makes sense is to require all hospitals to use the laboratory ID event. MRSA, bloodstream, and SSI infection data previously submitted by form has not

been evaluated. CDPH obtained a grant that provided an opportunity to fund eightfield IPs to facilitate the contact between the HAI program, local departments of public health, and local hospitals. They will be supporting local, regional, and statewide infection prevention collaboratives. While the above dealt only with inpatient acute care hospitals, outpatient facilities and even physician offices have been impacted with new regulations in the past year. CMS, through its agreement with the state, have begun rigorous surveys of ambulatory surgical care centers focusing on infection control. This is in response to the numerous large outbreaks that have occurred in these centers throughout the nation. These outbreaks have been linked to poor injection practices and a lack of infection control knowledge and infrastructure in these organizations. Individuals working with ambulatory surgery centers should expect that future surveys will be more in-

tense than past surveys. Many surveys have discovered that these outpatient facilities have failed to stay current with advances in hand hygiene, infection control training, and surgical site infection prevention, among other things. For an idea of what surveyors are looking for, visit: totalsol. vo.llnwd.net/o29/data/1080/infection_control_surveyor_worksheet.pdf. Lastly, in the midst of the H1N1 pandemic, California enacted the ATD standard. The ATD was broad, sweeping, and novel. Among the issues that caused the greatest difficulties was the standardâ&#x20AC;&#x2122;s requirement that healthcare workers use N95 respirators or greater when diagnosing, caring for, or treating patients with pandemic H1N1. This occurred at a time when there was a national shortage of these masks and no human outcome studies published to support

such a practice. As of this writing, the CDC says no such protection is necessary, but CAL-OSHA has yet to change the standard. More requirements are coming out of these standards, including the need to wear PAPRs when performing bronchoscopy unless there is a documented impact on patient safety. Among the more broadly accepted requirements is the need to offer vaccine free of charge to healthcare workers with a reasonable possibility of being exposed to an aerosol-transmissible disease. The regulation is far too lengthy to review here, but for more information on this regulation and how it may impact your practice, visit dir.ca.gov/title8/5199.html. As the year ends, physicians can be assured that prevention of healthcare-associated infections will continue to be a focus for payers, consumers, and regulators.

About the Authors: Mr. Meyers and Ms. Delahanty sit on SDCMSâ&#x20AC;&#x2122; GERM (Group to Eradicate Resistant Microorganisms) Commission. Ms. Delahanty is administrative director of infection prevention/clinical epidemiology and TB control at the UCSD Medical Center.

TUBCJMJUZ NBUUFST *G UIFSF JT POF UIJOH UP MFBSO GSPN UIF SFDFOU ÂšOBODJBM UVSNPJM LOPXJOH XIP UP USVTU JT QBSBNPVOU .FEJDBM 1SPUFDUJWF B QSPVE NFNCFS PG 8BSSFO #VGGFUUÂąT #FSLTIJSF )BUIBXBZ IBT BMXBZT CFMJFWFE UIBU UP QSPWJEF PVS IFBMUIDBSF QSPWJEFST UIF CFTU EFGFOTF JO UIF OBUJPO PVS ÂšOBODJBM TUBCJMJUZ OFFET UP CF SPDL TPMJE TUSPOHFS UIBO BOZ PUIFS DPNQBOZ 4UBCJMJUZ FWFO JO UIF XPSTU PG UJNFT .FEJDBM 1SPUFDUJWF JT UIF POMZ NFEJDBM QSPGFTTJPOBM MJBCJMJUZ JOTVSBODF DPNQBOZ UP QSPUFDU UIFJS IFBMUIDBSF QSPWJEFST UISPVHI BMM UIF CVTJOFTT BOE FDPOPNJD DZDMFT PG UIF MBTU ZFBST JODMVEJOH UIF UPVHI FDPOPNJD UJNFT PG UIF (SFBU %FQSFTTJPO 8F BSF BMTP QSPVE UP IBWF QSPWJEFE VONBUDIFE EFGFOTF BOE TUBCJMJUZ EVSJOH BMM UIF NFENBM DSJTFT

8F IBWF SFDFJWFE IJHIFS SBUJOHT GSPN " . #FTU BOE 4&1 UIBO BOZ PUIFS DBSSJFS JO UIF IFBMUIDBSF MJBCJMJUZ JOEVTUSZ

5SVTU 4UBCJMJUZ 5SVTU .FEJDBM 1SPUFDUJWF $POUBDU ,FWJO 4QJU[ UPEBZ GPS B NFENBM JOTVSBODF DIFDL VQ BOE B '3&& OP PCMJHBUJPO RVPUF $BMM .&%130 FYU &NBJM FYQFSUT!NFEQSP DPN 7JTJU XXX NFEQSP DPN $POUBDU ZPVS MPDBM .FEJDBM 1SPUFDUJWF BHFOU "MM QSPEVDUT BSF VOEFSXSJUUFO CZ FJUIFS 5IF .FEJDBM 1SPUFDUJWF $PNQBOZÂ&#x2C6; PS /BUJPOBM 'JSF BOE .BSJOF *OTVSBODF $PNQBOZ Â&#x2C6; CPUI #FSLTIJSF )BUIBXBZ CVTJOFTTFT 1SPEVDU BWBJMBCJMJUZ WBSJFT CBTFE VQPO CVTJOFTT BOE SFHVMBUPSZ BQQSPWBM BOE NBZ CF PGGFSFE PO BO BENJUUFE PS OPO BENJUUFE CBTJT Â&#x2030; 5IF .FEJDBM 1SPUFDUJWF $PNQBOZ Â&#x2C6; "MM 3JHIUT 3FTFSWFE

october 2010 SANâ&#x20AC;&#x2C6; DIEGOâ&#x20AC;&#x2C6; P HY SICIA N. o rg

Infectious Diseases

HIV testing Recommended As Part of Routine Patient C are

By James Marx, RN, MS, CIC

Note: Visit SDCMS.org to access this article’s references.

S AN D I E G O P HY S I CI A N . or g october 2010

There are 1 million people infected with HIV in the United States (population 307 million); 250,000 do not know they have HIV (.003 percent). In 2008, about one-third (32 percent) of individuals with an HIV diagnosis reported to CDC received a diagnosis of AIDS within 12 months of their initial HIV diagnosis. These late diagnoses represent missed opportunities for treatment and prevention. San Diego County has a population of 3 million; therefore, there are an estimated 2,400 San Diegans with undiagnosed HIV infection. Progress has been made in AIDS treatment; however, little has been done to increase diagnosis of HIV in unsuspecting individuals.

What Can San Diego Physicians Do? Offer routine HIV testing in our offices, clinics, emergency departments, and hospitals. Early HIV detection and treatment adds 17 years of life to the HIV-infected person. Most HIV infection is diagnosed after the development of AIDS symptoms. In 2006, the CDC recommended HIV testing of all patients seen during the course of routine medical care. Yet few providers offer testing. HIV testing no longer requires written consent. This requirement was dropped from California HIV testing laws in 2008 [Health & Safety Code 120990(a)]. Medical care providers are not required to get written consent, and processing laboratories are not required to get oral or written consent. Instead, medical care providers must do the following before ordering an HIV test: • Inform the patient that HIV testing is planned. • Provide information about HIV testing. • Inform the patient of treatment options if the test is positive. • Inform the patient who tests negative about being tested routinely. • Advise the patient they have a right to decline HIV testing. • Document in the medical record if the patient declines HIV testing.

Additional requirements are needed for pregnant women at the time of delivery who do not have HIV testing results in their prenatal record. Rapid testing must be done under these circumstances. There are six HIV rapid tests currently on the market. Here is a list of medical care provider obligations for pregnant women: • intent to perform an HIV test • explain the routine nature of the test • purpose of the test • risks and benefits of the test • risk of perinatal transmission of HIV and treatment options for the baby (50 percent reduced risk of transmission) • right to decline HIV testing Health & Safety Code Section 1367.46 and Insurance Code Section 101023.91 require healthcare service plans and insurance companies to provide coverage for HIV testing in medical care settings regardless of primary diagnosis.

Who Can Help Me With Implementing This in My Office, Clinic, or Hospital?

How Can I Start a Program in the Emergency Room? Specially prepared information is available for hospital emergency rooms seeking to incorporate routine HIV testing in their emergency department. Go to edhivtestguide.org. Consider joining a list serve of emergency care providers at hospitalconnect.com/secure/hret/hrethiv.jsp. You will need to consider the following: • assessing your hospital’s readiness • making the case for HIV testing • how to identify key players • measuring progress • costs and funding • legal considerations • operational flow • staffing • choosing the right testing method • training staff • informed consent • delivering and documenting results • linking to follow-up care

If you wish to add a local source for information on HIV testing, questions can be directed to the San Diego County Communicable Disease Investigator at (619) 6928501; or contact Sandy Simms, Chief, HIV Counseling, Testing, and Training, at (916) 449-5538 or email Sandy at Sandy.Simms@ cdph.ca.gov.

Progress has been made in AIDS treatment; Where Can I Get Educational however, little Material? has been done to increase diagnosis of HIV in unsuspecting individuals. Contact the California HIV/AIDS Clearinghouse at (888) 611-4222 or at cdph.ca.gov/ programs/aids/Pages/OACAC.aspx.

About the Author: Mr. Marx is an infection preventionist and sits on SDCMS’ GERM (Group to Eradicate Resistant Microorganisms) Commission

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases

antibiotic use in animals A C oncerning Situation in Need of Resolution By Norman J. Waecker Jr., MD, MPH

S AN D I E G O P HY S I CI A N . or g october 2010

Note: Visit SDCMS.org to access this article’s references. Note: Conflict of interest: None. Financial support: None. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States government.

What do we know about antibiotic use in animals? Most of us don’t think about giving antibiotics to well animals to promote growth and weight gain in raising livestock for food sources. Surprisingly, it has been estimated that up to 70 percent of all antibiotics sold in the United States are fed to healthy food animals for growth promotion, feed efficiency, and disease prevention. A major concern is that antibiotics are given routinely with feed and water to entire herds or flocks to compensate for overcrowded and unsanitary conditions. Logical questions would seem to follow: “Why is this being done?” “Are there problems with this approach in spilling over to the therapeutic use of antibiotics in medical practice?” “What are the implications and risks for this approach for our population?” Many of our medical societies have concerns about the overuse of antibiotics and subsequent development of antibiotic resistance. As drug-resistant organisms are increasing, antibiotics are becoming less effective to treat human infections, and today few new antibiotics are being developed. One important example is methicillinresistant Staphylococcus aureus (MRSA). It was recently estimated that there were 94,000 invasive infections with MRSA in the United States in 2005 and nearly 19,000 associated deaths. The Centers for Disease Control and Prevention (CDC) estimated that in 2002, 1.7 million hospital-associated infections and 99,000 deaths occurred in the United States, many of which were due to antibiotic-resistant infections. Increased costs are realized with drug resistant infections, longer hospital stays, and increased mortality. On March 17, 2009, the “Preservation of Antibiotics for Medical Treatment Act” (PAMTA) (HR 1549/SB 619) was introduced in the House of Representatives. This legislation was designed to help preserve the effectiveness of antimicrobials used to treat human infections. PAMTA would phase out

the nonmedical use of antibiotics in livestock, require higher standards for approval of animal antibiotics, and not restrict use of antibiotics to treat sick animals or to treat pets and other animals not used for food. According to the Infectious Diseases Society of America (IDSA), the FDA would do a safety review of growth promotion and routine disease prevention use in food animals of seven drug classes important for human medical practice. PAMTA is supported by greater than 350 organizations, including agricultural/farming, health, animal protection, consumer, environmental, and other concerned groups. Many professional medical and public health organizations support PAMTA, including the American Medical Association, the American Public Health Association, the American Academy of Pediatrics, and IDSA. Anticipated and documented problems with feeding antibiotics to animals for nontherapeutic uses may consist of promoting new strains of drug-resistant bacteria (“pig MRSA” ST398), spreading resistant organisms from farm workers to family members, finding resistant organism in retail meats, and promoting the spread of drug-resistant bacteria (e.g., Salmonella and Campylobacter) that can spread from animals — often through food sources — to cause infection in humans. According to the 2000 World Health Organization (WHO) report, an effort to reduce the use of antimicrobials in livestock was put in place. Growing evidence has revealed the impact of drug resistance on human health. In 1997, WHO recommended that antimicrobials normally prescribed for humans be prohibited as growth promoters in animals. WHO further recommended that

It has been estimated that up to 70 percent of all antibiotics sold in the United States are fed to healthy food animals for growth promotion, feed efficiency, and disease prevention. antimicrobials not be used as an alternative to high-quality animal hygiene. Studies have confirmed that farmers who stopped relying on antimicrobials as growth promoters in livestock have experienced no economic repercussions — provided animals were given enough space, clean water, and highgrade feed. Some special-interest groups oppose changing the status quo and support giving antibiotics to animals to promote physical growth; these groups encompass producers of most U.S. livestock and poultry. Animal welfare, food safety, and possible increases in production costs are among the reasons stated for maintaining the status quo. In a climate of rapidly rising antibiotic resistance, and with limited data to support the continuing use of antibiotics in animal feeds, more discussions and solutions need to be put on the table to resolve this concerning situation.

About the Author: Dr. Waecker is vice chair of the SDCMS GERM (Group to Eradicate Resistant Microorganisms) Commission. He is a fellow of the Infectious Diseases Society of America and is vice president of Infectious Disease Association of California. He has been a member of SDCMS-CMA since 2004.

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases

What’s all the about?

whoop

Resurgence of Pertussis in C alifornia

By Robert E. Peters, PhD, MD

S AN D I E G O P HY S I CI A N . or g october 2010

California is in the midst of another infectious disease epidemic. Not a residual H1N1 pandemic influenza threat, but an epidemic caused by Bordetella pertussis — the bacterium that causes whooping cough. Whooping cough’s primary clinical feature is the potential for a severe, lingering cough that can persist in many patients for weeks, if not months. In the 1920s and 1930s, pertussis was an annual concern as a feared childhood killer. National annual infection rates were as high as 250,000 cases with as many as 9,000 deaths each year. In the 1940s, health authorities introduced a combined vaccine against diphtheria, pertussis, and tetanus (DPT, now replaced with DTap). By 1976, in the United States, as a result of routine DPT vaccinations of children, pertussis in children had been virtually eliminated — there were only 1,010 cases reported that year. As healthcare professionals we know — and we must keep in mind — that pertussis outbreaks run in cycles. Cases tend to peak every three to five years as vaccine-induced immunity (in the general population) wears off. The last outbreak “peak” in California was in 2005, when 3,182 cases and eight deaths were reported. In 2010 we are running at a pace that suggests that the number of pertussis cases in California will reach a peak that will surpass the maximum observed cases, including deaths, in the past 50 years. As of Sept. 7, 2010, 3,834 cases have been reported in California, a seven-fold increase from the same period during 2009, when 530 cases were recorded. Our attention needs to focus first on unimmunized or incompletely immunized infants, a patient category that is particularly vulnerable. The 2010 epidemic has already resulted in the deaths of nine infants younger than three months. Most of these children were too young to have received a pertussis vaccination. Eight of the nine children who died this year were Hispanic. Statistics confirm that pertussis infection rates among infants are typically higher for Hispanics than for any other ethnic group in California. The clinical symptoms of pertussis can be difficult to distinguish from those of other respiratory infections. Symptoms may

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases

Our attention needs to focus first on unimmunized or incompletely immunized infants, a patient category that is particularly vulnerable.

S AN D I E G O P HY S I CI A N . or g october 2010

appear at first similar to those of a common cold: runny nose or congestion, sneezing, mild cough. Fever is often not present. At three weeks post-infection, 97 percent of patients will have a cough, and in 72 percent the cough will be severe (paroxysms). After more than nine weeks, 52 percent will still have a cough symptom. Infants and children with the disease cough violently, rapidly, and repeatedly, often with a loud “whooping” (69 percent) sound. Post-tussive emesis occurs in 65 percent. More than half of infants who are less than a year old must be hospitalized, and one in five will also develop pneumonia. About one in 100 will experience convulsions. Diagnostic testing is of relatively low sensitivity, particularly later in disease. Treatment is often delayed due to late presentation of the patient or late recognition by practitioners. Although treatment is important to reduce spread of infection, it may not influence the clinical course of the disease. Prevention is the best option. Children receive DTaP vaccine at 2, 4, and 6 months of age, with a booster at 15 to 18 months. An additional booster vaccination is given at age 4 to 6 years, typically linked to entering school. Infants must receive the first three shots in the vaccination series for maximum protection. There is now a vaccine for older children and adults, Tdap, which serves to boost the immunity that wanes after childhood immunization or natural disease. All children beginning at 11 to 12 years and all adults should receive a single dose of Tdap to renew their protection against pertussis. California’s effectiveness in accomplishing immunization of young children is better than the national average. In 2008, the coverage rate for three or more doses of DTaP among children 19 to 35 months of age was estimated to be almost 98 percent for California, compared to about 96 percent for the nation (CDC survey). California is not as successful (nor is the rest of the nation) at vaccination of children aged 11 and 12 years. In 2009, 53 percent of California children aged 13 to 17 years had received at

least one dose of Tdap. Unfortunately, only 6 percent of adults nationally have received their Tdap booster. California legislation is pending that would require children entering middle school to be vaccinated against pertussis. Boosting California’s immunization rates is also a goal of another proposed piece of legislation that would require health insurers to reimburse physicians for the full cost of purchasing, storing, and administering vaccines. A similar measure, co-sponsored by CAFP, was introduced in 2009 but died “in committee” due to financial reasons. Who should be vaccinated with Tdap? Since the source of infection for an infant is usually an adult, parents, family members, and caregivers of infants need a booster shot prior to providing care. Thus an ideal location for emphasizing immunizations is in obstetrics clinics and practices so that immunizations can be given during the last two trimesters, or at first follow-up after delivery. Others who are in routine contact with infants, including healthcare and childcare workers, should be vaccinated. The California Department of Public Health (CDPH) issued a new pertussis immunization recommendation with the objective of helping to curb the current pertussis outbreak.

CDPH Recommendation One dose: Tdap to anyone age 10 and older who is not fully immunized, including adults older than 64. This is especially important for individuals who care for infants and to women of childbearing age, either before they become pregnant, during pregnancy (the second or third trimester), or, failing that, immediately after the child’s birth. CDC recommendations include the substitution of Tdap for Td boosters for patients during an emergency department visit for wound management, unless the patient has already received a Tdap. There is also no need to wait for 5 to 10 years, as was historically traditional. Tdap can be given at any interval following a previous Td. Pertussis incidence waxes and wanes. It is not clear why California is experiencing current

Purchase additional copies of the first annual SDCMS San Diego County Physician Directory. This resource lists contact information for every physician in the county. 20100621redbook

6/22/10

5:37 PM

Page 1

(P.) (P.) (P.) • SECTION : LISTED ALPHABETICALLY SECTION : LISTED BY SPECIALTY AND ZIP CODE

San Diego County

Physician Directory  –

SDCMS Member Price: $8 Nonmember Price: $16

San Diego County Medical Society “Physicians United for a Healthy San Diego”

To purchase your copy, email Editor@sdcms.org

october 2010 SAN DIEGO P HY SICIA N. o rg

Infectious Diseases

Although treatment is important to reduce spread of infection, it may not influence the clinical course of the disease. Prevention is the best option.

epidemic proportions of the illness, and the most deaths in half a century. Numerous factors are suspected: • Cyclic nature of pertussis — and we are at the peak of a cycle. • Immunity has lessened in teenagers and also in older adults — protective immunity post vaccination begins to decline in four to 12 years. • Gaps in vaccination coverage — especially older children and adults. • Some doctors don’t offer the recommended immunization schedule because of a given patient’s economic circumstance and associated payment issues. As healthcare professionals, we must continually be aware that many infectious diseases that we no longer consider to be routine problems — and diseases that are no longer common in the United States — are only a plane ride away. Measles and mumps are common in Europe. Rubella is routine (outside the United States) worldwide. Diphtheria has been a problem in Russia and many of the former countries of the Soviet Union. Hepatitis is at relatively

high incidence in Africa and much of Asia, as well as in the Philippines and in certain parts of the Caribbean. Polio is not uncommon in sub-Saharan Africa and the Indian subcontinent. Keep in mind that San Diego had a measles outbreak only a few years ago. Mumps began to increase in incidence in June 2009 in New York City and in New Jersey, and is currently resurging, reported to be spreading primarily through the Orthodox Jewish communities. Each example of either a local or national epicenter of a given infectious disease — especially one that is effectively controlled by vaccination — reminds us of the ongoing need for vaccination and the advantages of herd immunity. As a society we must do a better job, both politically through legislation and professionally through our representation of the advantages and safety of routine vaccinations in our practices. The pertussis outbreak we are experiencing in California — and the deaths this year of nine infants — serves as a strong and immediately proximal reminder of the need for continued, effective vaccination programs.

About the Author: Dr. Peters, SDCMS-CMA member since 2000, is a family physician in private practice. He is a member of SDCMS’ GERM Commission, is secretary of SDCMS, co-chairs Sharp HealthCare’s Primary Care Conference, is a member of the bioethics committee at Sharp Memorial Hospital, and sits on CMA’s Council on Ethical Affairs. Dr. Peters also serves as a consultant to biomedical and pharmaceutical companies.

S AN D I E G O P HY S I CI A N . or g october 2010

Are You Taking Advantage of Your SDCMS-CMA Member Benefits? ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛ ˛

Are you getting your reimbursement issues resolved? Does your office manager have an ally she can turn to? Do you have a tough HR question you need answered? Are you protecting your assets? Is your bank working as hard as you? Are you saving on your professional liability insurance? Are you writing off bad debt unnecessarily? Is your prescription pad reorder rut costing you money? Are you squeezing all you can out of your health plan contracts? Is outsourcing your billing the solution? Have you done enough to prevent an IT meltdown? Is the right person doing your accounting? Are you unsure about a code and need it verified? Are your waiting-room magazines increasing your malpractice risk? Are you letting deadlines critical to your bottom line pass? Are you meeting your staff’s training needs? Are you getting stopped unnecessarily on your way to an emergency? Are you saving on car rentals? Are you or your spouse paying too much for car insurance?

Contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org today!

october 2010 SAN DIEGO P HY SICIA N. o rg

“

Volunteering for Project Access ALLOWS ME TO GIVE BACK to the San Diego community where I have practiced medicine for 29 YEARS. I enjoy knowing that I am providing for people who would otherwise not be able to obtain needed medical care, and MAKE A DIFFERENCE in their lives. – Dr. Leslie Mark, Skin Surgery Medical Group, San Diego

“

”

I’m enjoying my new eyes and SEEING THE WORLD AGAIN in living color. Words are not enough to express my thanks and GRATITUDE to Project Access San Diego, may you have more power to help more people like me.

”

– Leonora, Recipient Cataract Removal on December 6, 2008, and April 24, 2010

project access

volunteerism made easy

LET THE SDCMS FOUNDATION HELP YOU HELP THOSE WHO NEED IT MOST Project Access San Diego is modeled after a successful, nationwide program being implemented in 50 cities around the country. The heart of the program is to assist low-income, adult San Diegans who do not have private or public health insurance to receive the medical care they need. The SDCMS Foundation has partnered with more than 16 community clinic organizations in the county to provide these services. Physicians set their own volunteer commitment and ideally see one patient per month in their office for free. Please contact Lauren Radano, Healthcare Access Manager, at (858) 565-7930 or at Lauren.Radano@SDCMS.org if you have any questions.

Volunteer online today at SDCMSF.org! 32

S AN D I E G O P HY S I CI A N . or g october 2010

Professional Services Absolute Solutions

Sexuality Clinic of San Diego Cognitive/behavioral/psychodynamic therapy allows for understanding and treatment of sexual dysfunction, sexual addiction, and mental health problems. Relationships with others kindle thoughts in our minds about one’s self. The dramas are powerful and maintain their status at various levels of one’s psyche resulting in sexual and psychological turmoil. The therapeutic relationship with Dr. Silbert rn,cns,phd,faacs, promotes healing by trusting expression and freedom of the authentic self.

Absolute Solutions is a full-service consulting and outsourcing company dedicated to the healthcare industry. Our billing service uses state-of-the-art technology to ensure code validation, electronic submission/remittance, patient statements, structured follow-up/ appeals, electronic document storage and meaningful reporting. Consulting services include business development, credentialing, contracting, executive assistant, financialoperational practice management, relocation coordination and much more. Contact us today for your free consult!

619.326.0700 | www.abs-sol.com

858.483.1430 | www.sextherapyofsandiego.com

The Heffernan Group

Absolute Solutions International

The Heffernan Group is a wealth preservation firm, which specializes in retirement planning.

Scalable Outsourcing for Every Practice. Do you wish you had 10 more hours in your day? ASI can give you all the time your business needs! Services starting as low as $8.00 per hour total cost! • Accounts Receivable • Demographic Entry • Database Clean-up • Fee Schedule Updates • Online & Telephone • Payment Posting • Special Projects

• Asset Protection/Accumulation • Tax Sheltered Investments • Income Planning for the future • Tax Preparation Call us today for your free consultation CA License # 0E76547

619.692.0433 | www.theheffernangroup.com

Looking for a costeffective way to reach 8,500 physicians each month? Place your message here in the Professional Services page of San Diego Physician magazine. Rates starting at $250 for a six time contract. Contact: Dari Pebdani 858.231.1231 or DPebdani@sdcms.org

Call 619.326.0700

Your Company Name Here

Your logo here

Professional Services page ads: • Are cost effective • Target physicians and their staff • Get you monthly exposure • Build your business • Start at $250/month for six issues

Your Contact Info Here october 2010 SAN DIEGO P HY SICIA N. o rg

classifieds office space MEDICAL OFFICE SPACE AVAILABLE: La Jolla located campus Scripps Memorial Hospital. Consulting room. Two exam rooms. Private bathroom. Abundant parking. Recently decorated. Furnished optional. Call (858) 622-1052. [847] DOWNTOWN OFFICE SPACE AVAILABLE: Family practice physician in downtown San Diego has office space available. Preferably a primary care physician, but open to any healthcare provider. If interested, please call (858) 270-7633. [735] OFFICE SPACE AVAILABLE IMMEDIATELY: Adjacent to Tri-City Medical Center and North Coast Surgery Center. Provide large consultation room, two exam rooms. Conditions are negotiable. Full or part time. Free parking. Easy access to 78 or I-5. If interested, please email jean@tricitycts. com or call (760) 726-2500. [840]

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. FREE RENT INCENTIVES and a generous improvement allowance is provided. For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com OFFICE SPACE FOR LEASE: Medical Office space available 800–2,000ft2. Valet parking, walking distance to Mercy Hospital. To view call (619) 733-7497 or email crownpointbuilders@hotmail.com. [838] OFFICE SPACE IN HILLCREST: Office space available in Hillcrest at the Mercy Medical Building. Located directly across from Scripps Mercy Hospital. Excellent staff, state-of-the-art office and equipment. Please send letter of interest to KLewis@sdcms.org. [810] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price is very reasonable and appropriate for ENT, plastic surgeons, OBGYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medi-

cal, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 5045830. [835] 3998 VISTA WAY IN OCEANSIDE: Two medical office spaces approximately 2,000ft2 available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price: $2.20 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [834]

Recruitment, 393 East Walnut Street, Pasadena, CA 91188-8013. Phone: (800) 541-7946. Email: Glenn.Gallo@kp.org. AAP/EEO employer. http:// physiciancareers.kp.org/scal [850] PHYSICIANS NEEDED: Full-time, part-time, and per-diem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current Calif. and DEA licenses. Malpractice coverage provided. Bilingual: English/ Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic. org. EOE/M/F/D/V [846]

CARMEL VALLEY OFFICE SPACE FOR SHARED LEASE OR SUBLEASING: 2,900 square feet located in the Scripps Medical Offices on El Camino Real and High Bluff. Busy women’s health office ideal for physician seeking exposure to new patients. Convenient practice ready space ideal for a solo physician. Possibility for shared staff and/or overhead. Contact Mrs. Kim at cvwh858@gmail. com or at (858) 259-9821. [790]

INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group, a 350+ physician multispecialty group in San Diego, is seeking full-time BC/BE internal medicine physicians to join our staff. We offer a first year competitive compensation guarantee, excellent benefits package, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: Lori.Miller@sharp.com. [842]

NEW COMMERCIAL BUILDING IN LA MESA • SPACES FOR RENT/PRE-LEASE: Very close to Grossmont Hospital and highways 8 and 125. New building being constructed at 5980 Severin Dr., La Mesa. Near corner of Severin Dr. and Amaya, just north of the Brigantine restaurant. Beautiful and functional design. Spaces available from 1,000 to 5,500ft2. Pre-leasing/renting spaces. Call Nathan at (619) 787-3422 or email hythams@att.net. [823]

OBSTETRICIANS NEEDED: La Maestra Clinic is seeking to contract with obstetricians willing to do deliveries of our patients at Sharp Mary Birch, Scripps Mercy, or Grossmont Hospitals. We do all prenatal care, transfer to you at 36 weeks, then we resume care post-partum. No high-risk cases. Excellent opportunity! Interested? Contact David Priver, MD, OB/GYN Medical Director, at (619) 9873092 or at dpriver@aol.com. [839]

SHARE OFFICE SPACE IN LA MESA — AVAILABLE IMMEDIATELY: La Mesa (Grossmont Hospital Campus) 1,400ft2 available to an additional doctor. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648]

LOOKING FOR 1–2 NEUROLOGISTS TO JOIN OUR PRACTICE IN LA JOLLA: We are located on the campus of Scripps Memorial Hospital. This is a well-established (35+ years) practice. We have a strong referral base. Our practice treats neurodegenerative diseases with emphasis on dementias. We see a large number of movement disorder, stroke, and Botox treatment, as well as Parkinson’s disease. One of our physicians is the stroke director at Scripps Memorial Hospital, La Jolla. Outstanding earning potential and the option to expand into other areas is certainly a possibility. Email mrsbinx@hotmail.com. [837]

OFFICE SPACE TO SHARE: Currently occupied by orthopaedic surgeon. Great location close to Scripps/Mercy and UCSD Hospital. Looking to share with part-time or full time physician. Fully furnished, fully equipped with fluoro machine and 4 exam rooms and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950. [804] PHYSICIAN POSITIONS AVAILABLE OCCUPATIONAL MEDICINE OPPORTUNITIES, SAN DIEGO: The advantages of working with Kaiser Permanente Southern California reach far beyond our comprehensive network of support and state-of-the-art electronic medical records system. As part of our cross-specialty team, you’ll also have access to a compensation/benefits package that’s designed to impress you. If you would like to work with an organization that gives you the tools, resources, and freedom to get the best outcomes possible for your patients, join us in San Diego. Forward CV to: Kaiser Permanente, Professional

NORTH SAN DIEGO COUNTY FAMILY PRACTICE: We are a Joint Commission-accredited, federally qualified community health center, celebrating 40 years of service, and serving more than 60,000 patients in multiple locations in North San Diego County. We have opportunities for BC/ BE physicians. Compensation includes attractive base, incentive, and great benefit programs, malpractice, reimbursement for CME/licensure. This is an opportunity to make a difference in the lives of patients who are under- or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours. NHSC loan repay may also be available. Email cynthia.bekdache@nchs-health.org, call (760) 7368632, or fax to (760) 736-8740. [794]

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 $150 (100-word limit) per ad per month of insertion.

S AN D I E G O P HY S I CI A N . or g october 2010

ARE YOU STRUGGLING WITH YOUR PRIMARY CARE PRACTICE?:If you love your patients and you want to practice medicine the way you want, then Harmony Medical Group is a solution. We know the way to increase your productivity, cut expenses, and turn your practice from a nightmare to a joy. Please email us at harmonymedicalgroup@gmail.com and our business coordinator will meet and answer all your questions. [827] FAMILY MEDICINE PHYSICIANS — FULL AND PART TIME: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time or half-time job share BC/ BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Ave., San Diego, CA 92101. Fax: (619) 2334730. Email: Lori.Miller@sharp.com. [825] ORTHOPEDIST WANTED: Orthopedic office looking for an orthopedist, preferably a foot/ankle specialist. Please send CV and contact info to footandankleortho@gmail.com. [824] PSYCHIATRIST NEEDED: Home Physicians (thehousecalldocs.com) is a fast-growing group of house-call doctors. Great pay ($140–$200+K), flexible hours, choose your own days (full or part time). No weekends or inpatient duties. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [801] PART-TIME AND FULL-TIME OPENINGS FOR PRIMARY CARE PHYSICIANS: Board-certified family practice or internal medicine physicians wanted to join our prominent East County private medical group. One year or more experience preferred. Located on the Grossmont Hospital campus, our primary care group practices full-spectrum family medicine, including hospital care. Sharp Community Medical Group providers. Ownership opportunities available. Interested applicants please send CV to brad.kesling@gfmg.net. For further information, visit us at www.gfmg.net. [808] PHYSICIAN POSITION WANTED SEEKING EM POSITION: Board-certified emergency medicine physician with over 10 years experience seeking EM position in San Diego County. Please contact j_tran@earthlink.net. [841] PHYSICIAN POSITION WANTED: Female OB/ GYN in solo practice for over 20 years in Southern California seeking part- or full-time position in San Diego area. Insured. Clean background. Please contact norplex@hotmail.com. [833] PRACTICE FOR SALE 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] NONPHYSICIAN POSITIONS AVAILABLE WANTED CALIFORNIA-LICENSED CLS GENERALIST: For lead technologist for busy group practice. Must excel at multitasking and be able

to supervise lab assistants and other CLS while performing patient testing. Will oversee dayto-day operations, including quality control, lab workflow, and troubleshooting. Instrumentation includes Dimension Expand and Cell-Dyn. Strong technical background required. Two years plus experience preferred. Reports to lab director and technical consultant. Excellent benefits package. Salary commensurate with qualifications. Contact Lydia at (619) 229-5055. [845] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: We have an opening for a licensed midlevel practitioner (physician assistant or nurse practitioner) in our specialty practice. The successful candidate must be able to make focused patient assessments and have experience in clinical decision-making appropriate to a midlevel provider. We provide an environment of strong clinical support and access to supervising physician. We’re willing to make an investment in training the right candidate. The qualified candidate must be: graduate of an accredited program; current DEA certificate; Calif. license; Spanish speaking a plus; 2+ years of clinical experience. Please email cover letter, CV, and salary requirements to office@pacificsouthwestpain.com. [844] LOOKING FOR A MATURE, EXPERIENCED MEDICAL PRACTICE MANAGER: Twenty-hourper-week position. Established nephrology practice with two physicians and a third physician in the office in another specialty. Duties: The manager must have computer practice management and EHR experience. The manager must be familiar with all state and federal regulations pertaining to medical office management. The manager has to be able to evaluate and direct the office staff. The manager must be able to communicate and work with the four physicians in the office (there is a locum physician). The manage must be able to hire and fire people in a legal and professional way. The office is currently re-tooling with Allscripts; this is our software company as we move toward meaningful use. Dr. Ramenofsky’s wife is his account manager and works remotely. She is in charge of working with Allscripts to evaluate and re-tool the office to quality for the stimulus. The office manager will have to interact with her on a limited basis and then direct the office staff. Mrs. Ramenofsky also manages the hardware in the office, so that is one less duty the office manager has to perform. The entire office will re-train with the Allscripts academy onsite, the new manager will participate in this training for practice management and EHR. The manager will need to hold weekly or bi-weekly meeting with the staff to communicate and maintain high quality moral and work in the office. Contact Lauren Ramenofsky via her email: Buffmom1@aol.com. [843] MEDICAL ASSISTANT: Full-time medical assistant position available for general practice office. Four, 10-hour day shifts: Monday, Tuesday, Thursday, Friday. Office closed on Wednesday. Experience required. Please fax resume with cover letter to (858) 756-5952. If you have any questions, please call (858) 756-2340. [831] LOOKING FOR EXPERIENCED / LICENSED NURSE PRACTITIONER: Part time / full time, for a busy private primary care practice. Spanish helpful. National certification required. Location: Oceanside/Tri-City area. Compensation: competi-

tive. The nurse practitioner will provide general medical care and treatment to patients in the office. Under the direction of physician: Performs physical examinations and preventive health measures within prescribed guidelines and instructions of physician. The nurse practitioner orders, interprets, and evaluates diagnostic tests to identify and assess patient’s clinical problems and healthcare needs. Records physical findings, and formulates plan and prognosis, based on patient’s condition. Discusses case with physician to prepare comprehensive patient care plan. Submits healthcare plan and goals of individual patients for periodic review and evaluation by physician. Prescribes or recommends drugs or other forms of treatment such as physical therapy, inhalation therapy, or related therapeutic procedures. May refer patients to physician for consultation or to specialized health resources for treatment. Call (760) 639-1204. Fax (760) 630-1252. Email ncmaoceanside@hotmail.com. [830] OFFICE MANAGER WANTED: Mature, responsible adult with experience as office manager in cosmetic dermatology and surgery. Would also need to have experience in reception/front office and be willing to fill in there as needed. Sales experience helpful. Position would start part time and grow into full time. Would need to be available to cover vacations and sick call. We are a growing cosmetic dermatology/primary care practice with some minor officebased surgery. Duties would be primarily office managerial but would require occasional filling in when other employees are out. You would need to be able to manage employees, inventory, and be second point of contact for patients with questions or complaints. Good people skills are a must as well as a personable, sunny disposition. Starting pay $18 with performance increase in three months. Please email your resume with business references to drkenstanley@yahoo.com. [828] RECEPTIONIST WANTED: Mature, responsible adult with friendly, outgoing disposition for reception/front-office position. Experience in cosmetic dermatology preferred. Sales experience a must. Responsibilities include answering the phone, making appointments, collecting payments, selling products, and answering questions about services and products. You will be the primary point of contact for patients and potential patients. Must be willing and prepared to perform multiple roles as needed. Pay starts at $12/hour with a performance increase in three months. Please email your resume with business references to drkenstanley@yahoo.com. [829] MEDICAL EQUIPMENT SACRIFICE SALE: Slightly used, full-size hip and spine HOLOGIC Bone Densitometer. Price negotiable. Call (760) 703-0691. [755]

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

october 2010 SAN DIEGO P HY SICIA N. o rg

sdcmsfoundation By Paul Neustein, MD

Project Access San Diego A Unique Opportunity for Physicians to Volunteer in San Diego County While leafing through San Diego Physician magazine, I’ve come across multiple articles recounting medical volunteerism by colleagues. Some have ventured across continents, while others have gone just beyond the border. In all cases I have been impressed by the idealism and generosity of these physicians. As a solo practitioner, it is not feasible for me to commit the time away from practice that such volunteer activities would mandate. I was left to ponder, but not act upon, the possibility of volunteering my services in a meaningful way. Then one day I received a call from Dr. Rosemarie Johnson, an anesthesiologist. She identified herself as the medical community liaison for Project Access San Diego, a program begun by the San Diego County Medical Society Foundation to extend medical (and, in particular, surgical) services to indigent residents of our county who have no access to specialty care. Dr. Johnson had been referred to me at the recommendation of Dr. George Kaplan, our local pediatric urologist of national and international renown. When someone calls on the recommendation of George Kaplan, you take the call. We arranged a time for Dr. Johnson and Project Access manager Lauren Radano to

meet in my office. They explained the goals of the program, which were quite straightforward. I was impressed with the structure of the program, which was clearly designed with the practitioner in mind. Patients were to be screened prior to referral. Any pre-appointment questions would be directed to our office prior to the visit in order to maximize efficiency. The intent was to avoid irrelevant or unnecessary referrals and to identify those patients most likely to benefit from surgical intervention. Coordination with a hospital or surgery center, as well as anesthesia support, would be arranged by Project Access. Medical devices, when indicated, would be donated by various companies. The suggested schedule for new patient consults was one patient per month. Patient Maria S. is a married, 39-year-old mother of three who was referred for urinary incontinence. She required the use of multiple diapers daily. One additional visit was needed to corroborate the diagnosis of severe stress urinary incontinence. Through the coordinated efforts of Project Access, Palomar Pomerado Health System (PPHS), Anesthesia Consultants of California (ACC), and the Boston Scientific company, we were able to perform an outpatient urethral sling. The patient is now fully continent and much

better able to care for her family. Patient Analilia P., 34 years old, was referred for renal colic. She had already been diagnosed with an 11 mm renal calculus, way too large to pass. Recurrent pain had sent her to the ER with short-lived improvement. It was obvious when I first met her in the office that she was extremely uncomfortable. Again, with the collaboration of Project Access, ACC, and Health Tronics, the patient was successfully treated with shock wave lithotripsy. She is now pain-free. Most referrals have been as straightforward as the aforementioned cases. Obviously, if a diagnostic or therapeutic procedure is indicated, the time commitment on the part of the clinician, as well as the staff, extends beyond the immediate initial consultation. However, it is in the resolution of discrete, significant, treatable problems where the rewards are to be found. As one patient wrote in a note, “Thank you, Doctor. Now I don’t hurt anymore.” It doesn’t get any better than that.

{About the Author}

Dr. Neustein, SDCMS-CMA member since 1988, is a practicing urologist in Poway and volunteer for Project Access San Diego.

Interested in Volunteering?

Three Easy Ways to Sign Up!

1. Contact Lauren Radano, Healthcare Access Manager, at (858) 565-7930 or at Lauren.Radano@SDCMS.org. 2. Page Rosemarie Johnson, MD, Medical Community Liaison, at (619) 290-5351 or email her at RJohnson@SDCMS.org. 3. Visit SDCMSF.org and complete the physician volunteer commitment form.

S AN D I E G O P HY S I CI A N . or g october 2010

Cra�sman-Style Showplace Del Mar, California VIEWS, AMENITIES AND CRAFTSMANSHIP combine to offer a spectacular lifestyle at this beautiful home in Del Mar. The 6-bedroom, 5-full and 1-half-bath interior is detailed with stunning features, including 6 fireplaces (one is outside), 2 master suites, Brazilian cherry floors and heated marble floors in the master bath. The home is perfectly positioned to offer breathtaking white-water ocean views from the 2 covered west-facing porches and every westfacing room. The 24,000-square-foot lot is enhanced by gardens, dual driveways with ample parking plus garaging for 4 cars, and an outdoor living area with barbecue and fireplace. A canyon deck with pergola and a breathtaking saltwater pool with waterfall and Jacuzzi complete this premier Cra�sman-style residence. $8,900,000 Information from sources deemed reliable but not guaranteed.

Contact Robin for a private showing.

ROBIN A. EDWARDS

Broker/Owner DRE LIC #01864432 858.431.9305 E-mail: Robin@HomeAtLastToday.com www.RobinAEdwards.com

october 2010 SAN DIEGO P HY SICIA N. o rg

$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 ]

Mutualunderstanding You seek insight.

We provide expertise.

from NORCAL Mutual Register and complete CME courses at your convenience. Submit Attestation Forms online. Print transcripts and CME certificates. All from one easy-to-use Web site.

Our passion protects your practice

Learn more at www.norcalmutual.com/cme or call 800.652.1051, ext 2244

S AN D I E G O P HY S I CI A N . or g august october2010 2010