March 2011

March 2011

o ff i c i a l pu b l i c a t i o n o f

the san diego county medical society

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S A N D I E G O P HY S I CI A N .or g m a rc h 2011

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march 2011 SAN DIEGO P HY SICI A N. o rg

1

thismonth Volume 98, Number 3

features Medical Home

18 Is Your Office a Patient-centered Medical Home? Early 21st Century Medical Practice at Its Best

by Joseph E. Scherger, MD, MPH 20 The Patient-centered Medical Home and Multispecialty Medical Groups: Our Experience at SRSMG

by Steven A. Green, MD 22 Incorporating the Patient-centered Medical Home Into ACOs: A Pediatric Perspective

by Stuart A. Cohen, MD, MPH 24 Synergies of the Patient-centered Medical Home and the California Model

by John E. Jenrette, MD 26 The UCSD Division of Family Medicine’s Patient-centered Medical Home

by Gene “Rusty” Kallenberg, MD

departments

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, PhD, MD, 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 SDCMS Board of Directors Officers President Susan Kaweski, MD Past President Lisa S. Miller, MD President-elect Robert E. Wailes, MD Treasurer Sherry L. Franklin, MD Secretary Robert E. Peters, MD, PhD geographic and geographic alternate Directors East County William T. Tseng, MD, Heywood “Woody”

Zeidman, MD (A:Venu Prabaker, MD) Hillcrest Niren Angle, MD, Steven A. Ornish, MD Kearny Mesa John G. Lane, MD, 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) 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, Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Alan A. Schoengold, MD)

12

other board members Communications Chair Theodore M. Mazer, MD Young Physician Director Van L. Cheng, MD

4 SDCMS Seminars, Webinars, and Events

Mark Your Calendars!

Alternate Young Physician Director Kimberly M. Lovett, MD

4 Community Healthcare Calendar

Alternate Retired Physician Director Mitsuo Tomita, MD

Resident Physician Director Katherine M. Whipple, MD Alternate Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD Medical Student Director Adi J. Price

6 Briefly Noted

SDCMS Medical Office Manager Bulletin Board, and More …

CMA PRESIDENT-ELECT James T. Hay, MD CMA VICE SPEAKER OF THE HOUSE Theodore M. Mazer, MD

ex-officio, nonvoting board members

9 Get in Touch

CMA Past Presidents Robert E. Hertzka, MD (LEGISLATIVE

Your SDCMS and SDCMSF Support Teams Are Here to Help!

COMMITTEE CHAIR), Ralph R. Ocampo, MD CMA district I Trustees Albert Ray, MD, Robert E. Wailes, MD,

Sherry L. Franklin, MD

10 Medicare or Medi-Cal EHR Incentives:

CMA Trustee (other) Catherine D. Moore, MD

Which Is Right for You?

CMA SOLO AND SMALL-GROUP PRACTICE FORUM DELEGATES

Michael T. Couris, MD, James W. Ochi, MD

12 Health Information Exchange in San Diego: A Beacon for the Nation

16 Risk Management

How Safe Is Safe Enough?

16

ALTERNATE CMA SOLO AND SMALL-GROUP PRACTICE 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

34 Physician Marketplace

Classifieds

36 A Dinosaur’s Story

Hubris

2

S A N D I E G O P HY S I CI A N .or g m a rc h 2011

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

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21

calendar

sdcms Seminars / Webinars / Events Free to member physicians and their staff. For further information, contact Sonia Gonzales at (858) 300-2782 or at Sonia.Gonzales@ SDCMS.org, or visit SDCMS.org. Look to our January issue of San Diego Physician for a complete listing of SDCMS’ seminars, webinars, and events in 2011!

Outlook for Busy Docs (workshop) March 26, Saturday 8:00am–11:30am Anticipating Retirement (seminar/webinar) April 7, Thursday 11:30am–1:00pm

4

Best Practices in Revenue Cycle Management (seminar/webinar) May 5, Thursday 11:30am–1:00pm

community Healthcare Calendar Annual San Diego Science Festival March 19–26 • Petco Park • sdsciencefestival.com Allowing for Death: How Palliative Care Can Actually Prolong Life April 1 • Sharp Healthcare Spectrum, Spectrum Auditorium • (800) 827-4277 1st Annual San Diego Resuscitation Conference April 9 • Catamaran Hotel, San Diego 92109 • cme.ucsd.edu/ resuscitation

Medi-Cal County Presentations for Seniors and Persons With Disabilities April 27 • 10:00am–11:00am • Embassy Suites, 601 Pacific Highway, San Diego 92101 12th Annual UC San Diego Stroke Conference May 14 • cme.ucsd.edu/stroke

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

Preparing to Practice (workshop) May 7, Saturday 8:00am–4:00pm

Disciplinary Actions, Employee Terminations (seminar/webinar) April 14, Thursday 11:30am–1:00pm

Medi-Cal Updates (seminar/webinar) May 12, Thursday 11:30am–1:00pm

Resident and Young Physician Social (event) April 15, Friday 6:30pm–9:30pm

IT Update and Overview (seminar/webinar) May 19, Thursday 11:30am–1:00pm

Disclosure: Doing the Right Thing in the Right Way (two seminars/webinars) April 27, Wednesday 6:00pm–7:30pm April 28, Thursday 11:30am–1:00pm

The Leader’s Toolbox (workshop) May 20–21, Friday–Saturday 8:00am–4:00pm Coding Specifics: ICD-10 (seminar/webinar) May 26, Thursday 11:30am–1:00pm

S A N D I E G O P HY S I CI A N .or g m a rc h 2011

CMA Webinars & Events Coding for Medical Necessity and Quality Care (webinars) April 6, Wednesday 12:15pm–1:15pm, 6:00pm–7:00pm Implementing a Compliance Program (webinars) April 20, Wednesday 12:15pm–1:15pm, 6:00pm–7:00pm

Dealing With Sensitive Personnel Issues (webinars) May 4, Wednesday, 12:15pm–1:15pm, 6:00pm–7:00pm The Next Step: Successfully Negotiating Health Reform (event) 14th Annual California Health Care Leadership Academy June 3–5, Friday–Sunday • Renaissance Esmeralda Resort and Spa, Indian Wells 92210 • (800) 795-2262

Visit CMAnet.org/ calendar

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Febr uary 2011 SAN DIEGO P HY SIC I A N. o rg

5

brieflynoted

SDCMS Medical Office Manager SPECIAL FOCUS:

w Medical Records Guidelines Overvie tion for the release What is required for a valid authoriza the patient is seeking of medical records? To the extent that that grant patients a access to information under the laws tion, no particular rma right of access to their medical info request for access the that requirement applies other than the patient’s or ent pati the by be in writing and signed .05 et seq.). §§56 e Cod ty Safe & lth representative (Hea authorize that his or However, when a patient wishes to losed to a third party, her own medical information be disc orization is required then a particular form of written auth ical InformaMed of under the general Confidentiality Privacy Rules.

A HIPA the tion Act (CMIA), the IIPPA, and for a valid ents irem requ the For further information on ment #1101, docu L CAL ON’s CMA authorization, consult A, IIPPA, and the “Request by Other Third Parties: CMI free to SDCMS-CMA HIPAA Privacy Rules” — available members at CMAnet.org.

Q:

ased person’s medical reQ: Who can get access toaseda dece patient’s records is governed by

cords? Access to a dece Medical Information both the general Confidentiality of the laws governing a by and seq.)

Act (Civil Code §§56 et Safety Code §§123100 et patient’s right to access (Health & , healthcare providers seq.). Under the patient access laws ide copies of deceased must provide for inspection and prov time frames and patients’ medical records, under the are presented with otherwise as specified, whenever they

By Sonia Gonzales,

Your Off ice Manager Advocate 6

S A N D I E G O P HY S I CI A N .or g m a rc h 2011

a written request signed by a deceased patient’s agent pursuant to an advance directive , beneficiary, or person al representative (Health & Safety Code §§123105(e), 123110). Th e HIPAA Privacy Rules do not change thi s result (45 C.F.R. §164.5 02 (f)).

Q:

What are the recommende d retention periods for me dical records? The statute of lim itations in California gen erally requires that an adult’s action for medical malpractice be brought within “three years after the dat e of injury or one year aft er the plaintiff discovers, or through the use of reasonable dilige nce should have discovered, the inj ury,” whichever is shorte r.

For patients under the age of 18, a ma lpractice action must be brought within three years of the date of the alleged wro ngful act, except that patients under the age of 6 have at least un til their 18th birthday. The statute of limitations can be extend ed, however, if a patient can show fra ud or intentional concea lment on the part of the physician, or the presence of a foreig n object that has no therapeutic or diagn ostic effect. In addition, with respect to minors, it may be extend ed where the parent or gua rdian and the defendant’s insure r or healthcare provider commit fraud or collusion in the failure to bring an action on beh alf of the injured minor. Moreover , though the statue app lies only to cases of “professional neglige nce” broadly, it is possib le that cases involving contract or oth er disputes may be sub jec t to other statutes of limitation wit h broader tolling provis ion s. There are three recommended op tions: 1) Retain records ind efin itely; 2) Retain records at least 10 years after last date pat ien t is see n, with exceptions; and 3) Retain records 25 years after last date patient is seen. There may be pro visions in contracts you have signed with your medical malpr actice carrier, insurance companies, HMOs, etc., that specify as a minimum how lon g you need to keep records pertaining to at least some of your pat ients. This time period, if it exists, will vary with each con tra ct.

For further information on the req uirements for medical rec ord s retention, consult CMA’s ON -CALL document #1160, “Re ten tion of Medical Records” — ava ilable free to SDCMS-C MA members at CMAnet.org.

Save the Dates

The Best even ts and semina medical office rs managers! for

✓ MARCH 26: “Out look for Busy Doc s” ✓ APRIL 7: “Anticip ating Retiremen t” ✓ APRIL 14: “Disci

plinary Actions, Employee Term inations” ✓ APRIL 27, 28: “D isclosure: Doing the Right Thing in the Right Way ”

ER BENEFITS CtheOtreRasN ure trove of re-

ntage of • Have you taken adva SDCMS.org have been archived at corded seminars that your physito you for viewing with and which are available at Sonia. ail me, Sonia Gonzales, cian’s membership? Em CMS.org SD e to receive your uniqu Gonzales@SDCMS.org nars. rd to access these semi username and passwo can review mbership benefits you • For a current list of me nzales, at Go please call me, Sonia with your physician(s), (858) 300-2782.

CODING CORNER

by Michelle Pena, CPC, CHMB (CAHealth.com)

Question: I am receiving RTDs from Medi-Cal for missing modifiers on my office surgeries. Do I have to have a modifier on every surgical code?

Answer: Yes, all surgical procedures require a modifier when billing Medi-Cal. Surgical procedures include any code in the range Z1200–Z1212 or 10000–69999. The modifier AG is used to indicate the primary surgeon on the only surgical code or the code with the highest value. Append modifier 51 to each additional or lesser surgery. The procedure with modifier AG will be allowed at 100 percent of the Medi-Cal allowable, while the procedure with modifier 51 will be reimbursed at 50 percent. Note that add-on codes such as 11101 or 17003 will be allowed at 100 percent even with application of a 51 modifier. Be careful to familiarize yourself with the Medi-Cal website regarding modifier use. Bilateral surgeries or surgeries that require multiple modifiers have clear guidelines. Adhering to these guidelines helps avoid the painful cycle of correction and rebill or filing of CIFs/Appeals. Fantastic examples can be found under the Surgical Section of the Medi-Cal Manual Part 2, General Medicine. Look particularly at Surgery Billing Example: CMS 1500 and Surgery: Billing With Modifiers.

Reference: http://sdc.ms/3q

Contact Sonia at (85 8) 30 or at Sonia.Gonzales@ 0-2782 SDCMS.org

march 2011 SAN DIEGO P HY SICI A N. o rg

7

brieflynoted The PASD Corner

Let Your Legislators Know You’re Paying Attention, and That You Vote!

By Rosemarie Marshall Johnson, MD, Medical Community Liaison, Project Access San Diego, SDCMS Foundation Thanks to our generous physician specialist volunteers! In our brief 18 months of existence, Project Access San Diego (PASD) has provided over $2.5 million in specialty care for the working and other uninsured adults of San Diego County. As we review completed services, we marvel at the volume of successful care, and on many occasions we celebrate unique patient successes. Periodically we plan to share these stories in San Diego Physician as a tribute to the charity and devotion of the entire physician population of San Diego.

Last fall “Maria” presented with the need for a tracheostomy closure. Ten years ago, following stroke-induced difficulty in swallowing, a tracheostomy was performed, which was ready for closure in 2007. She could not obtain medical care for financial reasons so remained unable to speak until last fall when, through her community healthcare clinic, she was presented to PASD. With persistence and dedication by PASD staff, this outpatient operation was performed as our first case at Tri-City Hospital by our volunteers, otolaryngologist Dr. Julie Berry and anesthesiologist Dr. Margaret Burzynski of Anesthesia Service Medical Group. Maria was then able to speak to her family and to return to work for the first time since her stroke.

This is one of the many stories of charity care by our volunteer specialists but should make all physicians proud — it is replicated daily. We present this to share the advantages and successes of PASD. Although many physicians willingly provide charity care, PASD removes the hassle of donating care for our volunteer specialists and their office staff so they may treat a large segment of uninsured adults with increased satisfaction and efficiency.

8

S A N D I E G O P HY S I CI A N .or g m a rc h 2011

Birthday: MARCH 24

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! NOTE: Due to mail handling procedures for government office buildings, postal mail to Washington, DC, offices may be delayed by several weeks or even months.

Please fax or email if possible.

State Assemblyman Martin Garrick (District 74) E: (via website) arc.asm.ca.gov/member/74 E: assemblymember.garrick@assembly.ca.gov Sacramento Office: California State Assembly, PO Box 942849 Sacramento, CA 94249-0074 T: (916) 319-2074 • F: (916) 319-2174 Carlsbad Office: 1910 Palomar Point Way, Ste. 106 Carlsbad, CA 92008 T: (760) 929-7998 • F: (760) 929-7999

Birthday: April 13 U.S. Representative Susan Davis (District 53) E: (via website) house.gov/susandavis Washington, DC, Office: T: (202) 225-2040 • F: (202) 225-2948 San Diego Office: 2700 Adams Ave., Ste. 102 San Diego, CA 92116 T: (619) 280-5353 • F: (619) 280-5311

ERRATUM

In our January issue we neglected to include two longtime SDCMS-CMA members when we listed those physicians who’ve been members for 40 years or more. Our sincere apologies to Dr. Dann and Dr. Schonbrun, and thank you for your membership!



Myron Schonbrun, MD SDCMS-CMA Member Since 1968



Raymond Dann, MD SDCMS-CMA Member Since 1964

Get in

touch

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

healthcare communit y.

Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information

3 income Tax Planning

5575 Ruffin Road, Suite 250, San Diego, CA 92123

3 Wealth Management

T (858) 565-8888 F (858) 569-1334

3 employee Benefit Plans

E SDCMS@SDCMS.org

3 Profitability Reviews

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

3 outsourced Professional services (CFo, Controller)

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

3 organizational and Compensation structure

Director of Membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org

3 succession Planning

director of medical office manager support and Office Manager Advocate Sonia Gonzales at (858) 300-2782 or Sonia.Gonzales@SDCMS.org

3 Practice Valuations 3 internal Control Review and Risk Assessment

Director of Engagement Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org Director of Communications and Marketing Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org BUSINESS MANAGER Nathalia Aryani at (858) 300-2789 or Nathalia.Aryani@SDCMS.org administrative assistant Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org Letters to the Editor Editor@SDCMS.org General Suggestions SuggestionBox@SDCMS.org

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

SDCMSF Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123

ron mitchell, cpa director of health services

T (858) 565-8888 F (858) 560-0179 W SDCMSF.org Executive Director Kitty Bailey at (858) 300-2780 or Kitty.Bailey@SDCMS.org project access PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or Brenda.Salcedo@SDCMS.org

th

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Healthcare Access Manager Lauren Radano at (858) 565-7930 or Lauren.Radano@SDCMS.org

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advertising in San Diego Physician.

Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or at Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazes at (858) 565-8156 or at Elizabeth.Terrazes@SDCMS.org

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SDCMS member physicians receive

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

march 2011 SAN DIEGO P HY SICI A N. o rg

9

healthinformationtechnology

By California Health Information Partnership and Services Organization (CalHIPSO)

Medicare or Medi-Cal EHR Incentives Which Is Right for You?

INCENTIVE PROGRAM

MEDICARE

MEDI-CAL

Maximum Incentive

$44,000

$63,7502

Eligible Professionals

Physicians (MD or DO) Dentists Podiatrists Optometrists Chiropractors

Physicians (MD or DO) Dentists Nurse Practitioners Certified Nurse Midwives Physicians Assistants3

CalHIPSO, the California Health Information Partnership and Services Organization, is working with 10 Local Extension Centers (LECs) around the state to bring health information technology to local communities.

In San Diego and Imperial counties, the San Diego County Medical Society Foundation and the Community Clinics Health Network are providing technical services. If you are interested in learning more about CalHIPSO or in signing up, please visit the CalHIPSO website at www.calhipso.org or contact Rob Yeates at the San Diego County Medical Society Foundation at Rob.Yeates@SDCMS.org or at (619) 542-4357. To learn more about the incentive programs, visit the CMS website at www.cms.gov/EHRIncentivePrograms.

Eligibility Criteria

Most Medicare providers can qualify, but incentives will be based on a percentage (75%) of total Medicare charges.

Providers must meet one of three criteria: •30% of patient volume is Medi-Cal •20% of patient volume is MediCal (pediatricians only) •30% of patient volume is “needy individuals” (providers who practice in an FQHC)

If you are interested in learning more about CalHIPSO or in signing up, please visit the CalHIPSO website at www. calhipso.org or contact Rob Yeates at the San Diego County Medical Society Foundation at Rob.Yeates@SDCMS.org or at (619) 542-4357.

Penalties for Non-adoption

Yes, beginning in 2015.

No.

Upfront Funding

No. Providers can only receive funding for demonstrating meaningful use.

Yes. Funding is available for “Adoption, Implementation, or Upgrade” of an EHR system.

Timelines

Providers must demonstrate meaningful use in 2011 or 2012 in order to receive the maximum incentive.

Providers can begin in the program as late as 2016 and receive the maximum incentive.

Consecutive Years of Payment

Providers must demonstrate meaningful use in five consecutive years in order to receive the maximum incentive.

Providers can fail to demonstrate meaningful use for one year and still receive the maximum incentive (as long as all years fall before 2021).

Managed Care Patients

Medicare Advantage patients are not considered for the purposes of calculating provider incentives.

Medi-Cal Managed Care patients are counted for the purposes of meeting patient volume standards.

Eligible professionals can now register to participate in the Medicare and Medicaid EHR Incentive Programs. If you are eligible for both incentive programs, you must choose which program you wish to participate in when you register. Before 2015, you may switch programs only once after the first incentive payment is initiated; it is therefore important to consider carefully which

10

program to choose. The Medi-Cal incentive program offers higher possible incentives, but it requires that providers take a significant amount of Medi-Cal patients in order to qualify. The Medicare program has more aggressive timelines but lower overall eligibility requirements. The chart below summarizes the major differences between the two programs.

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

Notes: 1. Providers who practice in a Health Professions Shortage Area (HPSA) can receive a 10% bonus payment, making their maximum incentive $48,400.

2. Pediatricians whose Medi-Cal patient volume is between 20–29% will only qualify for two-thirds of the maximum incentive, or $42,500.

3. Physician assistants (PAs) only qualify for incentives if they practice in an FQHC that is PA-led.

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healthinformationtechnology

By Anupam Goel, MD, UCSD, Beacon Project Co-PI (SDCMS-CMA Member Since 2011), and Ted Chan, MD, UCSD, Beacon Project Co-PI (SDCMS-CMA Member Since 2005)

can show what care was delivered at all HIE-participating providers, medical offices, and medical centers that use electronic medical records (EMRs). With more information about the patient’s medical history, we believe an HIE will lead to better decisions about a patient’s care, resulting in fewer medical errors and improved health outcomes.

An HIE shares patient health data over a secure connection between authorized providers for patients who have consented to share their medical information.

Right Time for an HIE

Health Information

Exchange in San Diego A Beacon for the Nation The Office of the National Coordinator for Health Information Technology (ONC) has awarded San Diego $15.3 million to improve clinical care delivery using health information technology (health IT). The ONC chose San Diego as one of 17 “Beacon communities” to serve as a model for the rest of the country. The San Diego Beacon team has been meeting with medical groups and medical centers since April 2010 to determine the best application of these federal funds to improve our patients’ health. The project team chose three areas to focus upon: emergency medical services, public health, and transmitting patient in-

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

formation to providers across care settings.

All three areas require building a San Diegowide Health Information Exchange (HIE).

HIE and Healthcare How can a San Diego-wide HIE improve healthcare? An HIE shares patient health data over a secure connection between authorized providers for patients who have consented to share their medical information. Currently, when a provider reviews the patient’s chart, the available information is limited to what care was delivered by that provider, medical office, or medical center. With an HIE, the patient’s “chart”

Prior attempts to build an HIE (previously called “Regional Health Information Organizations (RHIOs)”) in this region have failed. Why is now the right time for an HIE in San Diego?

First, many San Diego providers already use EMRs, a prerequisite for exchanging data with others. As more and more providers adopt EMR systems as a part of federal incentive programs (see the July 2010 issue of San Diego Physician), our ability to share patient information across a majority of care delivery sites also improves. For those providers who are not yet on an EMR platform, the San Diego County Medical Society Foundation is leading a separate ONCfunded effort to assist with EMR adoption.

Second, EMRs are now able to transmit patient information in a structured way.

The federal government has established security and data exchange standards [i.e., the National Health Information Network (NHIN)].

Third, San Diego is already in the forefront of HIE development. The San Diego Veterans’ Administration (SDVA) and Navy Medical Center San Diego are already transmitting patient information on the NHIN. Kaiser Permanente San Diego (Kaiser) and

healthinformationtechnology Beacon Communities Across the Country: • Bangor Beacon Community, Brewer, Maine • Beacon Community of the Inland Northwest, Spokane, Wash.

• Central Indiana Beacon Community, Indianapolis, Ind. • Colorado Beacon Community, Grand Junction, Colo.

• Crescent City Beacon Community, New Orleans, La. • Delta BLUES Beacon Community, Stoneville, Miss.

• Greater Cincinnati Beacon Community, Cincinnati, Ohio • Greater Tulsa Health Access Network Beacon Community, Tulsa, Okla.

• Hawaii County Beacon Community, Hilo, Hawaii • Keystone Beacon Community, Danville, Pa. • Rhode Island Beacon Community, Providence, R.I. • San Diego Beacon Community, San Diego, Calif.

• Southeast Michigan Beacon Community, Detroit, Mich.

• Southeastern Minnesota Beacon Community, Rochester, Minn.

• Southern Piedmont Beacon Community, Concord, N.C. • Utah Beacon Community, Salt Lake City, Utah • Western New York Beacon Community, Buffalo, N.Y.

Organizations Participating in the San Diego Beacon Project: • Council of Community Clinics • Healthcare Association of San Diego & Imperial Counties • Kaiser Permanente San Diego • Naval Medical Center San Diego • Palomar/Pomerado Health System • Rady Children’s Medical Center • San Diego City Emergency Medical Services • San Diego County Health and Human Services Agency • San Diego County Medical Society • Scripps Health • Sharp Healthcare • UCSD Health System • VA Medical Center

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

the SDVA were initial NHIN sites, exchanging data on 1,500 San Diego veterans who also receive care at Kaiser. In addition, a number of community clinics have collaborated with hospital EDs to develop direct electronic exchanges to share information on mutual patients.

The San Diego Beacon Community As the only Beacon community in California, San Diego will be one of the state-designated HIE pilot sites. The state is looking for the San Diego Beacon community to address strategies to help patients understand the risks and benefits of participating in an HIE, authenticating patients and providers on the exchange, constructing meaningful views of patient health information that inform providers without overwhelming them, and building an exchange framework that is robust to changes in the health IT landscape.

The competitive San Diego healthcare marketplace can also threaten the project’s success. The ONC funding removes the financial hurdles to implementing an HIE, but money alone cannot make healthcare systems and providers work together to improve patient care. The ONC provided San Diego with these funds to specifically evaluate the ability of health IT to transform healthcare. Each participating medical group and medical center has committed to develop clinical processes and measurement tools to help us decide if the project should continue after the grant funds are exhausted. Fortunately, the San Diego Beacon is led by a collaboration of the major healthcare providers and stakeholders in our community.

The San Diego Beacon HIE Vision The San Diego Beacon vision is one where the HIE is integrated into clinical work-

flows. The HIE would add value at the pointof-care with accurate and reliable patient medical information from different sources (other providers, healthcare organizations, laboratories, pharmacies) to improve qual-

For those providers who are not yet on an EMR platform, the San Diego County Medical Society Foundation is leading a separate ONC-funded effort to assist with EMR adoption. ity and care coordination. Rather than store patient information centrally, the exchange will only store a patient index to determine which patients were seen at which facilities. When a request for patient data occurs, the exchange will retrieve the information from each medical center that has that patient’s information.

With the HIE, providers will be able to see an HIE-generated patient summary (medical history, medications, allergies, test results) through the provider’s own EMR. Providers who do not have an EMR will be able to access the HIE through a web portal. The provider will have the ability to click on a particular data element (e.g., CBC) to obtain additional information. In this way, the provider will be able to see a summary of clinical information aggregated from sources outside the provider’s own EMR. Clinical data will be available only when requested from the source and the following have been met: a) The patient is being cared for by the requesting provider; b) The patient has consented to participate in the exchange; and c) Both the source and receiving providers are HIE participants.

This strategy protects health data while enabling providers to get the information they need to take care of patients.

Benefits of Participating in the Beacon Community HIE

• Comprehensive view of a patient medical history, either within provider’s EMR or through a web portal • Access to patient data outside native EMR system • Care coordination and improved quality • Participation in a community HIE (meaningful use) • Automated reporting to Public Health (meaningful use) • Linkage to immunization registry with their patient-specific vaccination recommendations (meaningful use) • Connect to emergency medical services

Why Might You Participate?

As members of the San Diego provider community, we believe the Beacon project, coupled with changes in the way we provide care to our patients, has the potential to revolutionize healthcare. Besides the ability to review patient health information from multiple sources in a single, integrated display, the San Diego Beacon HIE will also connect to the San Diego Immunization Registry and the San Diego Public Health Department. These two connections satisfy two meaningful use criteria that are optional in 2011 but may become required in 2013. Moving forward, healthcare payers and regulatory agencies may also require HIE participation for payment of services or quality health reporting.

Provider participation will be necessary to make the San Diego Beacon project a suc-

The state is looking for the San Diego Beacon community to address strategies to help patients understand the risks and benefits of participating in an HIE, authenticating patients and providers on the exchange, constructing meaningful views of patient health information that inform providers without overwhelming them, and building an exchange framework that is robust to changes in the health IT landscape. cess. A public launch will occur later this spring. The launch will include describing the project, listing the project’s benefits to the community, and steps to involve patients. We expect to have the first live data transmission by mid- to late-summer with two medical centers who have agreed to participate on the exchange. As providers, medical groups, and medical centers meet the technical requirements to join the HIE, we plan to have more healthcare providers participate in the exchange over time.

We will provide additional information about the San Diego Beacon project in San Diego Physician magazine over the next few months. Please contact Karen Miller (ktm001@ucsd.edu) if you would like the San Diego Beacon project team to come out to your medical group to discuss the project in more detail.

2011 will be an exciting year for healthcare in San Diego, so please stay tuned!

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march 2011 SAN DIEGO P HY SICIA N. o rg

15

riskmanagement

By The Doctors Company

How Safe Is Safe Enough?

Is your office practice’s process as safe as it could or should be? Data from 525 site surveys in small-office practices, large, integrated delivery systems, hospitals, and in outpatient facilities such as surgery centers, using a standardized office assessment tool, revealed that medical record documentation was the category with the most frequent patient safety/risk management issues, followed by medication management, confidentiality and privacy, lab tests and referrals, and scheduling and follow-up. These last two categories are closely related, so a finding in one usually leads to a finding in the other.

Look at your own practice and use the following tips to protect your good practice of medicine: • Document allergy information in the same place on all medical records.

• Maintain a current list of patient medications, including herbal supplements and over-the-counter medications.

• Indicate in writing or electronically that all results of tests, consultants, and referrals were reviewed, and maintain the reports in the same place in all medical records.

• Do not rely on a return appointment or

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

placing a “hold” on the medical record to act as a reminder that a test was not performed or the patient was not contacted about results.

• Communicate all test results to patients, including those that are within normal limits (WNL).

• Avoid leaving messages on a patient’s voicemail unless you have been given specific permission to do so by the patient.

• Tell the patient to contact your office if he or she has not received results from you or your office staff by a specified date.

• Send letters to patients who fail to follow up and cannot be reached by phone; file all documentation and copies of letters in the medical record.

• Initial or sign labels of medications prepared prior to use, and include the name of the medication, the dosage, and the date.

• Identify all high-alert medications kept in your practice, and follow guidelines to ensure they are stored, ordered, dispensed, and administered correctly. Refer to the Institute for Safe Medication Practices website at www.ismp.org for more information on this topic.

• Provide education to all staff and prac-

titioners on the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) on an annual basis.

• Do a personal check of areas within your office where conversations with patients can be overheard by others. There are office buildings in which a conversation in one treatment room can be heard clearly in the next room.

Using data analysis from many sources enhances the ability to identify frequent loopholes in office practices and provide the most current and accurate patient safety information possible. For online tools such as the office practice assessment, National Patient Safety Foundation tools and more tips, visit www.thedoctors.com/psw.

About the Author: SDCMS-endorsed The Doctors Company provides its members with MediGuardSM core coverage, which protects against regulatory risks including Medicaid and Medicare RAC allegations.

MediGuardSM PLUS is an enhanced coverage available to members and includes higher limits and expanded features. For more information, visit www.thedoctors.com/mediguardplus.

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march 2011 SAN DIEGO P HY SICIA N. o rg

17

Medical Home

Is Your Office a Patientcentered Medical Home?

Early 21st-century Medical Practice at Its Best

By Joseph E. Scherger, MD, MPH

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

Note: A version of this article, titled “The Essence of the Medical Home,” was published by Dr. Scherger in Medical Home News, Health Policy Publishing, LLC. May, 2010 (www.medicalhomenews.com).

T

he patient-centered medical home means different things to different people. Position papers and articles go on at length describing the principles and applications of the medical home model. After reading such pieces, I often wonder just how the medical home is different from the good traditional medical office practice. Too often the trees are being described without first making clear what the new forest is all about.

The essence of the medical home model can be described in eight words: care coordination by a team independent of visits. If you only use two words, they are care coordination. Traditional office practice reacts to those patients who make appointments.

Information systems that allow for strategic proactive care to a population are missing. In a medical home, the population cared for becomes clear, and efforts are made by the care team to reach out proactively to achieve better outcomes.

For example, a medical practice would know all its patients with diabetes. Those patients could be placed into three buckets: good control, fair control, and poor control.

An analysis of who was coming into the office for care would probably show that those in good control were more likely to be coming in for regular appointments, and those in poor control were not. If the practice truly takes responsibility for the care of all its diabetic patients, the practice would reach out and contact the patients in fair and poor control and strive to improve their care proactively.

The additional payment in the medical home model is for the care coordination outside of visits. There are two payment methods emerging. I will call them low payment and higher payment. The low payment method, such as $2–4 per member per month, is common in Medicaid applications of the medical home. This amount of money gives a practice the funds to hire a care coordinator as part of the team. This person or persons reach out to patients, usually by telephone, to get patients back into the care system. Outcomes improve, and visits to the emergency department and even hospital-

izations may decline. The rest of the team, including the physician, continues to practice in the same way with a busy office schedule of mostly brief visits.

The higher payment method, such as $30–50 per member per month, allows for a redesign of the care model away from a dependence on office visits. This payment allows the entire care team, including the

The essence of the medical home model can be described in eight words: care coordination by a team independent of visits. physician, to communicate with patients on a new platform, such as online and the telephone. Visits are done selectively and more time intensively to establish care relationships and provide essential visit-based care.

More productive interactions with patients occur outside of visits each day than face-toface encounters. A new care model emerges with physicians seeing about 10–12 patients per day in longer appointments and spending one to two hours per day in care coordination activities. This new model of primary care has the potential of attracting more medical students to primary care and avoiding burnout among providers. It is the new primary care for the information age.

Proactive care coordination by a team supported by information systems is the new care model. As it becomes the new primary care, such care coordination will migrate into specialty care, as those office practices also should use care coordination by a team independent of visits to provide higher quality continuity of care to patients. The American College of Cardiology has placed the medical home as a high priority, and progressive cardiology practices are becoming proactive with patients with heart disease and related chronic conditions. Any practice caring for patients over time, such as a rheu-

matology practice with its arthritis patients or a neurology practice with its movement disorder patients, should apply the methods of proactive care. Even a surgical practice, such as in orthopedics with a joint replacement patient, should be a medical home for that patient from the day of the initial consultation to the rehabilitation after surgery.

Strategic, proactive care using the patientcentered medical home model achieves better outcomes in the many applications where it has been studied (see pcpcc.net for list of medical home applications and outcome studies). It is early 21st-century medical practice at its best. When our computers give us a snapshot of our practice population, a new dynamic of reach-out care follows, especially if the payment system supports this activity beyond office visits.

About the Author: Dr. Scherger, SDCMSCMA member since 2003, is vice president for primary care at Eisenhower Medical Center in Rancho Mirage. Dr. Scherger is a former editor of San Diego Physician.

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march 2011 SAN DIEGO P HY SICIA N. o rg

19

Medical Home

The Patient-centered Medical Home and

Multispecialty Medical Groups Our Experience at SRSMG S

By Steven A. Green, MD

20

S AN D I E G O P HY S I CI A N. or g m a rc h 2011

harp Rees-Stealy Medical Group (SRSMG) has a head start on many of the elements of the patient-centered medical home (PCMH). The principles of PCMH lend themselves well to a multispecialty group like ours, where more than 60 percent of our patients are capitated. The joint principles of the patient-centered medical home include having a personal physician, physician-directed medical practice, wholeperson orientation, along with integrated, coordinated care. Quality and safety are hallmarks of the medical home, along with enhanced access to care with advanced access scheduling, expanded hours, and new options for communication between patients and their physicians. SRSMG has been a leader in San Diego County in all

these areas. Discussion of PCMH has led to a focus on practice redesign with the idea of continuing to improve how we deliver care.

Having a personal physician has long been important at SRSMG. People with more chronic or complicated medical problems benefit enormously from having someone who knows them and their medical conditions. We all realize it is much easier for a physician who already knows a complicated patient to evaluate a new problem, as they know how the patient usually looks and acts. From a patient’s perspective, it is not only comforting to see someone they have known over time, but they have less explaining to do during their visit.

Teams of caregivers are important as well.

In general most physicians at SRSMG have an MA or LVN working directly with them for a long time. The continuity for the physician, MA, or LVN, as well as for the patients, helps us work together better. We use nurse practitioners and physician assistants in many of our practices who, under the physician’s guidance, help manage patient care.

In addition to the one-to-one nursing, the ancillary staff works together to meet the patient’s needs. Diabetic educators, dieticians, as well as clinical pharmacists help care for patients at the direction of the physician.

Experts on PCMH recommend having staff work to the full potential of their license.

The idea is to free up the physician when possible by having a nurse or other health professional work under his or her guidance.

This can allow the physician more time to work with the more complex patients.

Having an integrated electronic health record (EHR) is something none of the doctors in our group would ever give up. While no EHR is perfect, our 400 doctors have the advantage of accessing a patient’s history in any exam room, office, hospital, or even at home, improving our ability to deliver high-quality and timely care. I can remember 10 years ago when a patient called with a question, and just getting his or her paper chart could take half the day or more, while the patient waited for a call back. That delay has disappeared. We all know docs can have less than stellar handwriting, and trying to struggle through an illegible note is not only frustrating, but can compromise care.

That too has disappeared with the EHR.

Being able to communicate electronically between primary and nonprimary care is also valuable. Rather than having to call a consultant with a question, I can now ask a question right from the exam room with the patient there.

We have long had patient registries and the ability to work proactively to manage our patients with various disease entities.

Exactly what a patientcentered medical home will look like will vary depending on whether it is a large multispecialty medical group like SRSMG, a smaller practice, or a single-specialty medical group.

Outreach to our more difficult patients is important. If a patient with poorly controlled

diabetes doesn’t show up for an appointment, or cancels and doesn’t reschedule, we will reach out to them to schedule another appointment, reminding them to do their previsit labs and bring in their blood glucose logs. This type of outreach to patients has helped us become one of the best-performing medical groups in California in the payfor-performance program as well as other quality programs.

One of our latest innovations is mySharp patient portal where patients can communicate with their physician’s office electronically, schedule appointments, view most lab results and clinical data. This can even be uploaded to Google Health if they so choose. While there was some initial apprehension that more work would be created for the physician, most doctors now think this is more efficient and is just the right thing to do. The patients certainly seem to like it.

In addition, many of our physicians have been using advanced access scheduling for years now. The idea is to do today’s work today. Making the visit types more standard-

ized and using known principles to be able to predict demand, we can do a better job of getting an appointment for our patients.

Exactly what a patient-centered medical home will look like will vary depending on whether it is a large multispecialty medical group like SRSMG, a smaller practice, or a single-specialty medical group. Whatever it is called, the elements within a PCMH seem to be things that make sense. At SRSMG we will continue to look at our practice and work to optimize the care we provide to our patients.

About the Author: Dr. Green, SDCMSCMA member since 1999 and current North County geographic alternate director on SDCMS’ board of directors, has practiced with Sharp Rees-Stealy Medical Group (SRSMG) since finishing his residency in 1988, and currently chairs the department of family medicine and the Council of Department Chairs. He also serves as speaker of the Congress of Delegates for the California Academy of Family Physicians.

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march 2011 SAN DIEGO P HY SICIA N. o rg

21

Medical Home

Incorporating

the Patient-centered

Medical Home

into acos A Pediatric Perspective M

By Stuart A. Cohen, MD, MPH

22

S AN D I E G O P HY S I CI A N. or g m a rc h 2011

uch has been written lately about the efforts to structurally reform the delivery and payment of healthcare services in the United States. Faced with ever-increasing costs, hastened by an aging population and the expansion of newer and more expensive healthcare technologies, we compare poorly to other countries as measured by life expectancy and mortality rates, despite spending a much greater proportion of our gross domestic product on healthcare.

Recent federal legislation, the Patient Protection and Affordable Care Act (PPACA), however flawed in the eyes of physicians and organized medicine, contains provisions for Medicare and Medicaid demonstration projects through the use of Accountability Care Organizations, or ACOs. ACOs attempt to restrict the growth of healthcare costs and improve quality of care and outcomes by integrating physicians together into entities that achieve savings through enhanced coordination of care, promoting evidencebased medicine, meeting defined standards for patient-centered care, and using electronic healthcare medical records and e-prescribing to closely track clinical per-

formance measures and cost benchmarks.

There is also the inherent mandate to develop the legal and administrative structures to receive and distribute the shared savings from decreased hospitalizations and/or emergency room and urgent care costs.

While hospitals, state and regional health plans, and IPAs are rushing into the process of developing alliances and forming ACOs that would function in both the publicly funded as well as commercial health coverage arena, administrative rules and antitrust issues have yet to be fully ironed out by CMS, OIG, DOJ, and Congress. Both Northern and Southern California are dominated by a few health plans and major hospital systems, as well as several large IPAs. Issues of market dominance and most-favored nation contracts may be impediments to the current concept of ACOs. Bundling of high-cost services (e.g., hip replacement, coronary artery disease) do lend themselves to California’s tradition of capitation, but do we have the precise risk adjustment capabilities to make it work?

How are we going to fund EHR acquisition for the many small and solo practices that wish to join an ACO, let alone the administrative and legal structures required?

How can ACOs work without the capital and administrative savvy of a large hospital partner? What will the emergence of newly insured (through the PPACA’s mandate of health insurance exchanges) patients with pent-up demand for healthcare services be on established provider systems? Will proposed expansion of scope of practice by nurse practitioners and ancillary health professions help or hinder current provider business models?

While these issues are still unanswered, pediatricians have their own particular concerns over healthcare reform. Dr. Cal Sia, a prominent pediatrician from Hawaii, pioneered the concept of the medical home for the American Academy of Pediatrics in the mid-1960s. Meant to be medical care for children that was family and patient centered, comprehensive, culturally competent and sensitive, and providing 24-hour, seven-days-a-week coverage. It was an idea dormant in the rest of organized medicine till the beginning of this century, when it was co-opted by all the other primary care organizations as a way of enhancing

payment and preserving primary care as a viable part of our healthcare delivery system. Almost all current pediatric practices, large and small, operate on the tenets of the patient-centered medical home (PCMH).

Many are officially already accredited by various organizations, such as NCQA, AAAHC, and the JCAHO. From a pediatric perspective, if we exclude children with special healthcare needs who are covered under Title V federal benefits (known as CCS in California), who will have their own ACO demonstration projects, the hospitalization rates for all other children may not be large enough to provide the cost savings expected in a Medicare-type population. Legislation for Medicare ACOs mandate a minimum of 5,000 patients. Medicare costs and premium revenue are three to four times as much per member compared to the pediatric population. Does this mean a pediatric demonstration ACO will need a minimum of 10,000 to 20,000 pediatric patients to scale up to the expected savings of a comparable

Medicare ACO, or are we comparing apples to oranges?

In conclusion, healthcare payment reform seems to mandate a shift from the PCMH to an ACO with PCMH as component, involving providers taking on performance risk on a large scale, with electronic medical record systems and administrative and legal structures developed to meet all the potential legal and financial barriers. Whether or not pediatric systems and hospitals can stand alone in such a process or will need to be integrated into multidisciplinary systems of care with subsidized shared savings across the continuum of care is an unanswered question at present.

About the Author: Dr. Cohen, SDCMSCMA member since 1988, practices pediatrics with Children’s Primary Care Medical Group, is a past president of the San Diego County Medical Society (SDCMS), current president of the SDCMS Foundation, and current vice chair of the American Academy of Pediatrics, California Chapter.

ACOs attempt to restrict the growth of healthcare costs and improve quality of care and outcomes by integrating physicians together into entities that achieve savings through enhanced coordination of care, promoting evidence-based medicine, meeting defined standards for patient-centered care, and using electronic healthcare medical records and e-prescribing to closely track clinical performance measures and cost benchmarks.

march 2011 SAN DIEGO P HY SICIA N. o rg

23

Medical Home

Synergies of the

Patientcentered Medical Home and the California Model T

By John E. Jenrette, MD

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S AN  D I E G O  P HY S I CI A N. or g m a rc h 2011

he patient-centered medical home (PCMH) model was introduced as early as 1967 by the American Academy of Pediatrics (AAP). In broad terms the model provided care that was accessible, continuous, comprehensive, and coordinated, and delivered in the context of family and community. More recently the PCMH model was identified as a key to healthcare reform, and, according to AAFP president Rick Kellerman, MD, a medical home would improve healthcare quality and cost effectiveness while better integrating patient care into the overall healthcare system and increasing patient satisfaction.

On a national level, unlike California, primary care physician offices are becoming certified through NCQA, and practices who choose such a path must comply with standards in categories including: 1) access and communication; 2) patient tracking and registry functions; 3) care management ac-

tivities; 4) patient self-management support; 5) electronic prescribing; 6) test tracking; 7) referral tracking; 8) performance reporting and improvement; and 9) advanced electronic communications. Details of NCQA certification for the PCMH can be reviewed at www.ncqa.org.

Recent discussions regarding the relationship of PCMHs and accountable care organizations (ACOs) outlined in the Affordable Care Act have suggested that the PCMH is the key element and may well lie at the heart of the ACO. The PCMH provides the link to enhanced patient self-management of disease, increased effectiveness through use of coordinated evidence-based care, and improvement of access to care through open scheduling and expanded hours, along with new options for communications and coordination, and/or integration across all elements of care, including practices, hospitals, nursing homes, and consultants within the healthcare system.

Early outcomes data for both quality and cost efficiency for PCMH interventions are still being collected. Results appear promising, and improvements in the patient experience, care coordination, and access are being demonstrated. Direct savings have also been shown through reduced emergency department visits, inpatient hospitalizations, and decreased lengths of stay in skilled nursing facilities.

If PCMHs enhance the delivery of care in both quality and cost saving and are recognized as an integral element of healthcare reform, why is it that the state of California has not embraced PCMH models as widely as other parts of the country, as evidenced

by NCQA certification? The answer appears to be two-fold. The first is the very nature of the California coordinated care model that has been developed for HMO products and the second is the lack of incentives and payment reform required to move primary care practices in the direction of PCMHs. The California coordinated care model has been extremely successful at controlling costs while improving quality for large populations of patients. Many of the tenants of the PCMH are already included and have been provided by the medical groups and IPAs who have refined and transformed medical care for more than 20 years under the HMO model. These services include

after-hours access, same-day appointments, population management, including preventive screening and services, disease management, chronic care management, care coordination, transitions of care between different silos of medical services, medication management, and health information technology.

Based on this success, private payers and public sectors have not initiated payment methods that would further advance and transform primary care into the new PCMH model. Medical groups and IPA organizations, having already been successful in providing many of the services inherent to the PCMH model, have not been convinced that the investment in the new models will be worthwhile.

Given this backdrop, there remain many opportunities and gains to be made in advancing the PCMH model. Primary care physicians should be involved in the comprehensive and collaborative care of their patients for both acute and chronic conditions but too often have been stuck in an old

model of episode-based medicine. They have lost the continuous relationship and wholeperson care that are fundamental underpinnings of primary care. Improvement can be made to create mindful clinician-patient communication and reinstill the trust, respect, and shared decision-making of primary care.

Primary care physicians are a key element to advance quality improvement and cost effectiveness to an even greater extent than provided by our current models. We now have an opportunity to transform or reinvent primary care offices and improve physician satisfaction with their practices as well as the satisfaction of their staff and patients.

Our challenge is — and therefore our goals should include — additional education and training for primary care offices such that a “healthcare team” is created for each primary care location, and within these teams each individual can perform at “the top of their license” to care for an entire population and coordinate services throughout the entire continuum of care. This requires a

culture change at the primary care level that would help us attract medical students and residents to primary care practice opportunities and ultimately practice in offices where a more positive and patient-centered model of care can be experienced.

As organizations we must also improve compensation for primary care offices that move into the PCMH model and provide health information technology that will help support them as they improve access and provide improved population management and care coordination.

The payoff to creating PCMHs will include not only heightened levels of satisfaction for physicians, office staff, and patients but also more efficient delivery of services at the primary care level that will be necessitated by the new models created under healthcare reform.

About the Author: Dr. Jenrette, SDCMSCMA member since 2010, is chief executive and medical officer of Sharp Community Medical Group.

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Medical Home

The UCSD Division of Family Medicine’s

Patient-centered Medical Home T

By Gene “Rusty” Kallenberg, MD

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

he Division of Family Medicine at UCSD has been steadily building its patientcentered medical home (PCMH) since the Future of Family Medicine Project Report was first published in 2004. Among other goals this document stated that the PCMHs of the future would have a “basket of services” that would allow the delivery of 85–90 percent of patient care needs within the PCMH itself.

This was a restatement of a long-held principle of family medicine and represented “comprehensiveness” of services — one of the five “Cs” of primary care (first contact, continuity, comprehensiveness, coordination, and family/community context) first enunciated by the IOM Report on Primary Care in 1996. These concepts were reaffirmed in 2007 when all three primary care organizations adopted the joint principles of the PCMH: personal physician, physician-

directed medical practice, whole-person orientation, care is coordinated and/or integrated, quality and safety, enhanced access, and payment reform.

At UCSD we have been working hard to create a PCMH that provides the fullest range of services possible. We are greatly assisted in this effort by our outstanding EPIC Systems electronic medical record (EMR), now used throughout the UCSD Medical Center. EPIC provides a complete view of all visits — from ER to primary care to specialty to inpatient — and all laboratory, radiology, and special testing results. Medications can be refilled easily and electronically without the need to pick up physical paper prescriptions. In addition, through its Webportal “MyUCSDChart,” patients can email their physicians or communicate with family medicine office staff about appointments, review their laboratory results, and keep abreast of their health maintenance and preventive screening needs.

Our newest EMR efforts allow us to develop patient registries for special groups of patients with particular diseases (e.g., diabetes or heart failure) or particular needs (smoking cessation or care management) so that we can more easily follow up on those who are not doing as well as they could. We are developing care management tools and processes to really focus on those patients with special needs so that we can give them the best care possible. An example of these is our group medical visits where we invite a group of patients with chronic medical conditions and their significant support person(s) to meet with our health psychologist and their family doctor for a series of evening group meetings where they really get to focus on improving their health behaviors related to their own specific medical challenges. Our EPIC EMR truly augments our ability to provide the right care to the right patient(s) by the right person(s) at the right time.

In addition to the complete range of preventive, acute, and chronic care services provided by all our family doctors, we also have developed a wide range of additional care to really complete our “basket of services” and provide 85–90 percent of the care any one of our patients might need — right in our PCMH family medicine offices. These include: 1. Our Sports Medicine Service and Fellow-

ship Program, which provides evaluation and treatment of common sports medicine injuries, and other musculoskeletal and arthritis problems. Our

In addition to the complete range of preventive, acute, and chronic care services provided by all our family doctors, we also have developed a wide range of additional care to really complete our “basket of services” and provide 85–90 percent of the care any one of our patients might need — right in our PCMH family medicine offices. sports medicine doctors can handle pretty much everything short of operative interventions requiring an orthopedist.

2. Our Obstetrical Service, which offers routine prenatal care and delivery services, including C-sections provided by our six family practice faculty who are certified to do obstetrics along with all of our family medicine residents who participate in this care. This service also provides office gynecologic procedures, including IUD insertions, endometrial biopsies, and colposcopies for further evaluation of abnormal Pap smears.

3. A full range of office procedures, including our “Lump and Bump” clinic where two of our family practice faculty, who have years of experience in office dermatology and surgery, perform excisions, biopsies, and minor plastic procedures.

This allows us to greatly reduce our need for referrals to dermatology for most of the common dermatologic problems seen in primary care. We also provide vasectomies and flexible sigmoidoscopies for those patients requiring such services.

4. Our Collaborative Care Team, which

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provides a full range of mental health/ behavioral counseling and psychiatry consultative services. In a joint program with USD’s Marriage and Family Therapy Program, we field in-office, immediately available counseling services with therapists who can work in close conjunction with the patient’s family doctor to treat common individual mental health problems like depression and anxiety, and also relationship and family problems as well. Our consulting psychiatrist, a graduate of our own Combined Family Medicine and Psychiatry Residency Program, provides psychiatry consultations in all of our offices. Finally, our therapists provide individual and group therapy for health behavior change that patients may need assistance with in order to improve their chronic disease conditions like diabetes or smoking cessation.

5. Our Pharmacy Services include participation by students, residents, and faculty from the UCSD Skaggs School of Phar-

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Medical Home

Next, UCSD Family Medicine will begin to extend into the community with liaisons to key community-based resources that can assist patients in achieving their health goals. This is now being referred to as the “patientcentered medical neighborhood,” and it represents the next phase of PCMH development.

macy for patients who have complicated medication regimens and for those who need counseling on how to purchase their medications as cheaply as possible through Medicare Part D programs. Our pharmacists assist our family doctors in managing patients who need additional instruction and education on how to take their medications properly and to their best advantage.

6. Integrative medicine services will be our newest offering in our PCMH as the Division of Family Medicine will be the host for the new UCSD Center for Integrative Medicine (CIM), and we will soon be offering integrative medicine consultations and complementary and alternative (CAM) services with licensed clinicians in acupuncture and traditional Chinese medicine (TCM) at each of our offices. Additional mindbody, nutrition, and other CAM services will be available through other CIM clinicians like Dr. Steve Hickman, who directs the UCSD Center for Mindfulness.

As one can see, the UCSD Division of Family Medicine’s PCMH effort is developing the widest possible range of services to offer its patients and their families. Next, UCSD Family Medicine will begin to extend into the community with liaisons to key community-based resources that can assist patients in achieving their health goals. This is now being referred to as the “patient-centered medical neighborhood,” and it represents the next phase of PCMH development.

About the Author: Dr. Kallenberg, SDCMS-CMA member since 2005, has been chief of the Division of Family Medicine and vice chair of the Department of Family and Preventive Medicine at UCSD since 2001. His interests include new models of primary care, mental health, primary care collaboration, integrative medicine, and medical education in the areas of communication skills, the doctor-patient-family relationship, health systems, and professionalism.

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* The Specialty Care Access Initiative (SCAI) is a program of the Council of Community Clinics and the San Diego County Medical Society Foundation. SCAI is made possible with funding from Kaiser Permanente.

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classifieds office space OFFICE SPACE FOR RENT IN POWAY: Medical office space for lease, 1,215ft2. Office has furnished waiting area, front and back stations for four staff members, two exam rooms, a break room, and a doctor’s office.

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Located in a great medical/dental complex in Poway, close to Pomerado Hospital, on the border with Rancho Bernardo. Second floor. Elevator/stair access.

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ability, as well as provide convenience for patients/clients. Through managing a portfolio of over 100 shopping centers across San Diego County, we can advise you of space opportunities suitable for your business.

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Please send CV to SRSMG, Physician Services, 2001 Fourth Ave., San Diego, CA 92101. Fax: (619) 233-4730.

Email: lori.miller@sharp.com. [901] LOOKING FOR A PART-TIME PHYSICIAN — bilingual Spanish a plus — to permanently join our group

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.

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practice of three physicians and six providers in the San Diego/Chula Vista area. Family medicine or internal medicine preferred. The opportunity can become full time as well as eligible for partnership in this well-established (30 year) group. The office is exceptionally well run, efficient, and friendly, and is completely on EHR. Respond by email with CV to sharpgate@yahoo.com or contact our office manager Connie Espinoza for additional information at conniee4@gmail.com. [900] LOOKING FOR EXPERIENCED FAMILY PRACTICE OR INTERNAL MEDICINE PHYSICIAN: Interested in working in a community clinic setting. Our corporation recently converted to electronic medical records and would need to have some computer experience. Salary and benefits are dependent on qualifications and years of experience. The site is in the Linda Vista area close to Fashion Valley Mall and USD. We have great hours with no hospital call. Physician should be available to work 32–36 hours a week. If interested, email CV to awalton@Lvhcc.com. [897] SEEKING BOARD-CERTIFIED / BOARD-ELIGIBLE FAMILY PHYSICIAN: To work in solo family practice office in Chula Vista. Excellent work environment and staff support in a well-established, patient-centered practice. Open to flexible hours. Must have excellent communication skills, bilingual in Spanish preferred.

Must have a compassionate and caring attitude. Please email CV and interest to ann@padillamd.com or fax to (619) 422-1324. [896] P/T FAMILY PRACTICE PHYSICIAN NEEDED FOR A BUSY, FEDERALLY QUALIFIED HEALTH CENTER IN ESCONDIDO: MHCS is a mission-driven organization that serves both rural and urban residents of San Diego County. We have been in business for 35 years and offer a competitive salary. Board certified and bilingual English/Spanish preferred.

Send CV to hr@mtnhealth.org or (619) 478-9164.

You may contact HR directly at (619) 478-5254, ext.

30. www.mtnhealth.org. [894] CHIEF MEDICAL OFFICER TO SERVE FOUR FEDERALLY QUALIFIED HEALTH CENTERS: MHCS is a mission-driven organization that serves both rural and urban residents of San Diego County. We have been in business for 35 years and offer a competitive salary, medical benefits, vacation, paid holidays, sick time, CME reimbursement, and license reimbursement. Board certified family practice and bilingual English/Spanish preferred. This position will require 60 percent clinical and 40 percent administrative.

Contact Tabitha at (619) 478-5254 or at hr@mtnhealth.org. [893] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private, nonprofit, outpatient clinic serving the communities in North San Diego County, has openings for part-time and per-diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. [887] FAMILY PRACTICE PHYSICIAN: Three positions available. Full-time family practice or internal medicine/pediatrics in Temecula (physician: Temecula).

Full-time family practice or internal medicine in Escondido at clinic as well as at a skilling nursing facility (physician: Grand). Full-time family practice in Escondido (physician: Elm). All positions provide comprehensive medical services for members of family, regardless of age or sex, on continuing basis.

Candidates must have current California medical license, DEA and CPR certifications. Please send CVs to Dr. Jim Schultz via email at JimS@nhcare.org or

fax to (760) 796-4021, Attn: Physician — Date. Please indicate which position (Temecula, Grand, or Elm) is desired. [884]

transitioning to EHR. Must be outgoing, proactive, flexible, and willing to work with small staff. Fax resume to (619) 298-4250. [891]

PHYSICIANS: RETIRED W/LICENSE? WANT TO CUT BACK TO TWO DAYS?:Alternative care office in Carlsbad Village looking for California licensed MD for consultative work. Part time, excellent compensation. Contact James Gould at knewidea@gmail. com or at (760) 703-3767. [880]

EXPERIENCED MEDICAL INSURANCE BILLER/ COLLECTOR needed for busy orthopedic and occupational therapy office: Must have excellent AR collections skills and proven abilities. Workers’ compensation experience a must and excellent understanding of their reimbursement as well as other third-party payers. Must have the ability to work accounts and denials, including re-determinations, appeals, and collections procedures.

Candidates should be able to work independently, organized, pays attention to details, and motivated.

Minimum of two years experience, high school diploma or general education degree. Thirty-two a week.

Excellent benefits. Salary based on experience.

Please fax resume to (619) 718-4122. [890]

SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/ vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 fulltime). [778] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.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 ER call or inpatient duties required.

Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [801] INTERNAL MEDICINE, PART-TIME POSITION, PRIVATE PRACTICE, WONDERFUL JOB OPPORTUNITY!:Outstanding opportunity to work part time or more in a mature, premiere private practice setting in North San Diego County, outpatient only. This unique position blends the rewards of private practice and traditional continuity of care with scheduling flexibility. Perfect for any physician who wants to transition from the demands of a full-time position, or who wants to maximize job satisfaction in an extremely high quality work environment while still working part time. Contact (619) 248-2324 for more information. [861] 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 SEEKING NURSE PRACTITIONER / PHYSICIAN ASSISTANT: To work in solo family practice in Chula Vista. Excellent work environment and support in a well-established, patient-centered practice with flexible hours. Must have excellent communication skills, bilingual in Spanish preferred. Must be experienced with a compassionate, caring attitude and able to practice independently with appropriate backup.

Please email CV and interest to ann@padillamd.com or fax to (619) 422-1055. [895] FULL-TIME OFFICE MANAGER / MEDICAL BILLER: Busy Hillcrest OB/GYN practice. Pay and 401k eligibility based on experience. Medical manager

PSYCHOTHERAPIST: Full-time position (40 hours per week) open at our behavioral health clinic in Escondido. The staff psychotherapist does individual, family, and/or group psychotherapy with children and/or adolescents and/or adults. Also designs, markets, conducts, and evaluates health promotion programs for smoking cessation, weight management, stress management, and other types of health promotion groups. Candidates must have PhD in psychology or counseling or a master’s degree in social work. Two years of experience is preferred. Please send applications/resumes to Matt Holden, PhD, via email at MattH@nhcare.org or fax to (760) 796-4021, Attn: Psychiatry — Date. [888] FAMILY NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Two positions available. Full-time position (40 hours per week) and part-time position (24 hours per week) open at our clinic in Temecula. The FNP or PA provides healthcare services to patients under direction and responsibility of physician. Candidates must have a current California PA or FNP license, DEA and CPR certifications. Please send CVs to Dr. Jim Schultz via email at JimS@nhcare.org or fax to (760) 796-4021, Attn: FNP/PA — Date. Please indicate which position (FT or PT) is desired. [885] BILLING PERSON NEEDED: We are looking for a billing person to fill the position that we currently have open. Here are the requirements: full-time; Monday – Friday 8:00 – 4:30 with a half hour lunch; UTC area with free parking; busy orthopedic office, solo practice; full medical and dental benefits; must have minimum of five current years of workers’ compensation experience. Send resume with salary requirements to slevine@northcountyomg.com. [883] PART-TIME NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Busy family practice with strong geriatric population located in downtown is seeking full- or part-time nurse practitioner or physician assistant. Experience in EMR preferred. Must be fluent in Spanish and English. Please fax resume to (858) 270-7633. [881] MEDICAL EQUIPMENT EXAM TABLE FOR SALE: $100 or best offer. Please contact us at (619) 298-6701. [892] CHART RACKS FOR SALE: Three free-standing metal chart racks for sale in very good condition.

Each rack has nine shelves with four metal dividers per shelf. Dimensions are 36” wide by 92” tall by 13” deep. Each chart rack can hold approximately 575– 625 charts, depending on size. These chart racks cost over $600 each brand new. Asking $375 or best offer. Email KLewis@SDCMS.org. [879]

march 2011 SAN DIEGO P HY SICIA N. o rg

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adinosaur’sstory

By F. Bruce Kimball, MD

Hubris Neurosurgeons and orthopedists have had a turf battle over treatment of spinal diseases and trauma all during my career. My training included surgery for lumbar disc disease but not intrathecal surgery.

One such instance here in San Diego, long before CTs and MRIs, involved a patient of mine who complained of lancinating pain down one leg, especially when she coughed or laughed. I suspected a cauda equina tumor and referred her to a neurosurgeon. The doctor called me to say he thought she had a simple disc rupture, so obvious he saw no need for a myelogram. I asked about a tumor, but he did not agree.

On the day of surgery, I reported on time only to find a delay while the surgeon performed a myelogram. The myelogram showed a cauda equine tumor!

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S AN D I E G O P HY S I CI A N. or g m a rc h 2011

My neurosurgeon could not bring himself to admit he was wrong. The operation was performed in total silence. Somehow the patient chose me for follow-up care.

The reverse of this situation occurred a few years later involving a cervical spine injury.

I advised a spinal fusion, the neurosurgeon in charge (not the same one) advised nonsurgical care. I was wrong. The patient did very well under conservative treatment. I called the doctor to congratulate him. It was a short conversation: not a “Thank you,” not even a gloat or two. He simply hung up. Arrogance and hubris!

Another difference of opinion was in the surgical approach to lesions in the spinal canal. The traditional neurosurgical method was posterior, a laminectomy. When the

lesion was anterior, manipulation of the cord often paralyzed the patient. Furthermore, laminectomy left no stock of bone for stabilization.

Gradually surgeons began to work from the front. In the last 25 years there has been a complete reversal. The anterior approach is here to stay. Maybe the turf battle war is over.

About the Author: Dr. Kimball, who first joined SDCMS-CMA in 1957 and was editor of San Diego Physician — then known as The Bulletin of the San Diego County Medical Society — in 1960 and 1961, is now both a retired member and a retired orthopedic surgeon. San Diego Physician is happy to publish a series of articles by Dr. Kimball under the rubric “A Dinosaur’s Story.”

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