October 2011 by San Diego Physician

official publication of the san diego county medical society october 2011

Infectious

Disease “Physicians United For A Healthy San Diego”

One stolen laptop — 2,000 exposed patient records.

Let us shield you. Patient information can be lost or stolen in many ways. But when it happens, you’re the one who must clean up the mess and incur the expense. DataShield, a coverage enhancement from NORCAL Mutual, protects you from costs related to information and network security— at no additional cost to you. Call us at 800-652-1051. To find out more visit norcalmutual.com/datashield Proud to support the San Diego County Medical Society.

S A N D I E G O P HY S I CI A N .or g O c tob e r 2011

Our passion protects your practice

Octo ber 2011 SAN DIEGO P HY SIC I A N. o rg

thismonth Volume 98, Number 10

features infectious Disease

20 Gastroenteritis Caused by Noroviruses: An Update on This Highly Infective Pathogen by Robert E. Peters, PhD, MD 26 Immunizations: Doctors Need to Do More Than Just Give Shots!

by Mark H. Sawyer, MD, FAAP

30 Healthcare-associated Infections:

Year Three (2011) Legislative Update by Kim Delahanty

departments 4 Briefly Noted SDCMS and CMA Seminars, Webinars, and Events Community Healthcare Calendar And More … 7 Your Monthly Benefits Check-up

Vital Benefit Seminars & Webinars Physician Advocate Q&A and More …

by Linda Louise Hill, MD, MPH

SDCMS Board of Directors Officers President Robert E. Wailes, MD (CMA Trustee) President-elect Sherry L. Franklin, MD (CMA Trustee) Treasurer Robert E. Peters, PhD, MD Secretary J. Steven Poceta, MD Immediate Past President Susan Kaweski, MD geographic and geographic alternate Directors East County William T-C Tseng, MD, Heywood “Woody” Zeidman,

MD, Kimberly M. Lovett, MD (A:Venu Prabaker, MD) Hillcrest Theodore S. Thomas, MD, Steven A. Ornish, MD, Jason P. Lujan, MD (A:Gregory M. Balourdas, MD) Kearny Mesa John G. Lane, MD (A:Marvalyn E. DeCambre, MD, Sergio R. Flores, MD) La Jolla Gregory I. Ostrow, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Douglas Fenton, MD, Niren Angle, 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, Peter O. Raudaskoski, MD, Mihir Y. Parikh, MD, Suman Sinha, MD (A: Carol L. Young, MD, Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD) other voting members Communications Chair Theodore M. Mazer, MD (CMA Vice Speaker) Young Physician Director Van L. Cheng, MD Resident Physician Director Steve H. Koh, MD Medical Student Director Beth P. Griffiths

OTHER NONVOTING MEMBERS Young Physician Alternate Director Renjit A. Sundharadas, MD Resident Physician Alternate Director Christina Pagano, MD Retired Physician Alternate Director Mitsuo Tomita, MD CMA President-elect James T. Hay, MD

by Tom Gehring

18 Mandated Disease Reporting Requirements: A Roadmap

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 Art Director Lisa Williams Copy Editor Adam Elder

Retired Physician Director Rosemarie M. Johnson, MD

12 The Great Southern California Blackout of 2011

Managing Editor Kyle Lewis

14 The Total Economic Impact of Physicians in San Diego County

by Tom Gehring and Thomas Chippendale

CMA Past Presidents Robert E. Hertzka, MD (Legislative Committee Chair), Ralph R. Ocampo, MD CMA Trustee Albert Ray, MD CMA Trustee (OTHER) Catherine D. Moore, MD CMA SSGPF Delegates James W. Ochi, MD, Ritvik Prakash Mehta, MD CMA SSGPF Alternate Delegates Dan I. Giurgiu MD, Ashish K. Wadhwa, MD

34 Physician Marketplace Classifieds

36 The First North County Project Access Surgery Saturday by Rosemarie Marshall Johnson, MD

2 SAN DIEGO PHYSICIAN .org Oc tober 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.]

“We call First Republic and instantly talk to someone who truly helps us with our account.” MICHAEL HALLS, M.D., F.R.C.S.(C), F.A.C.S. (LEFT), MUNISH K. BATRA, M.D., F.A.C.S. (RIGHT) CO-FOUNDERS, DOCTORS OFFERING CHARITABLE SERVICES (DOCS)

p r i vat e b a n k i n g

•

w e a lt h m a n ag e m e n t

•

b ro k e r ag e

•

trust

1-800-221-9333 • www.firstrepublic.com • new york stock exchange symbol: frc • member fdic brokerage services provided through first republic securities co., llc. member finra / sipc

3 3

sept August ember 2011 SAN DIEGO P HY SIC SICII A A N. N. o o rg rg 3 Oc tob er 2011 SAN DIEGO PHYSICIAN.org Octo ber 2011 SAN DIEGO P HY

brieflynoted featured member

calendar SDCMS SEMINARS & WEBINARS SDCMS.org/event

How to Oversee Your Biller(s) OCT 27 • 11:30am–1:00pm Media Training (workshop) OCT 29 • 8:00am–12:00pm Changes to Medicare Regulations NOV 2 • 11:30am–1:00pm HIPAA Transactions and ICD10: Are You Ready? (webinar only) NOV 9 • 11:30am–1:00pm The Leader’s Toolbox (workshop) NOV 11, 12 • 9:00am–4:00pm Litigation Traps for Surgical Practices NOV 16 • 6:30pm–7:30pm Litigation Traps for Surgical Practices NOV 17 • 11:30am–12:30pm HIPAA 5010 JAN 12 • 11:30am–1:00pm Workplace Harmony JAN 18 • 11:30am–1:00pm Legislative Advocacy Training (workshop) JAN 21 • 8:00am–12:00pm EHR and Documentation Risk Issues JAN 25 • 6:30pm–7:30pm EHR and Documentation Risk Issues JAN 26 • 11:30am–12:30pm

CMA WEBINARS CMAnet.org/calendar

Key Financial Ratios to Increase Profitability OCT 26 • 12:15–1:15pm • 6:15–7:15pm Risk Management and Longterm Care: Understanding Your Options NOV 1 • 12:15pm–1:15pm Electronic Health Records Update NOV 2 • 12:15–1:15pm

EHR: Meaningful Use NOV 9 • 12:15–1:15pm • 6:15–7:15pm Top 10 Ways to Save Your Practice Money NOV 16 • 12:15–1:15pm • 6:15–7:15pm Medicare 2012: Final Rules DEC 7 • 12:15–1:15pm

COMMUNITY HEALTHCARE CALENDAR TEDMED 2011 at the Hotel del Coronado OCT 25–28 • Where the world’s most creative minds meet healthcare’s most innovative science. TEDMED celebrates conversations that demonstrate the intersection and connections between all things medicaland healthcare-related: from personal health to public health, devices to design, and Hollywood to the hospital. Together, this encompasses more than 20 percent of America’s GNP while touching everyone’s life around the globe. Apply today to attend this amazing event as space is limited. Always a sold-out event! Exclusive spots reserved for physicians in San Diego. Apply online at www.TEDMED.com/ register, and, upon acceptance, enter the Group Code: SD2011. Serving Seniors and People With Disabilities OCT 26 • 12:30pm–2:30pm • Free training luncheon and networking opportunity for providers and medical staff. • DoubleTree Hotel, Mission Valley • hsd.hhsa@ sdcounty.ca.gov 6th Annual Sharp HospiceCare Conference: Caring for Endof-Life Patients in the Age of Healthcare Reform NOV 5 • Paradise Point Resort and Spa • www.sharp.com/classes (select CME from dropdown menu) 3rd Annual Heart and Vascular Conference 2011: Awareness, Prevention, and Intervention NOV 5–6 • La Costa Resort & Spa, Carlsbad • $125 • sharp.com/ classes

4 SAN DIEGO PHYSICIAN.org Oc tober 2011

5th Annual UC San Diego Hands-On Endoluminal, Single Site, and NOTES Surgery Symposium DEC 1–3 • Hard Rock Hotel San Diego • cme.ucsd.edu/notes/ index.html 2011 Military Healthcare Convention and Conference San Diego DEC 5–8 • www. militaryhealthcareconvention. com 9th Annual Natural Supplements: An Evidencebased Update JAN 19–22 • Hilton San Diego Bayfront Brain Tumors: 2nd Annual Collaborative Care Conference JAN 21 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ braintumors Timmy Global Health Mission Trip to Ecuador MAR 10–17 • Clinics seeing approximately 40 patients per provider per day. • www. timmyglobalhealth.org Topics and Advances in Internal Medicine MAR 12–16 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ internalmed Topics and Advances in Pulmonary and Critical Care Medicine MAR 17–18 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ internalmed California Orthopedic Association Annual Meeting APR 19–22 • Park Hyatt Resort in Carlsbad • www.coa.org/coaannual-meeting.html 13th Annual Science and Clinical Application of Integrative Holistic Medicine NOV 2 • Hilton San Diego Resort

Dr. Stuart A. Cohen Dr. Cohen, SDCMS-CMA member since 1988 and current chair of the American Academy of Pediatrics (AAP) delegation to CMA, was recently appointed vice-chair of the AAP delegation to AMA. Congratulations, Dr. Cohen! If you would like to be considered for our next “Featured Member” spotlight, please email Editor@SDCMS.org. Thank you for your membership in SDCMS and CMA!

public health

County of San Diego Epidemiology Program The County of San Diego Epidemiology Program works to identify, investigate, register, and evaluate communicable, reportable, and emerging diseases and conditions to protect the health of the community. Services offered by the Epidemiology Program include: • Diseases and Conditions • Disease Information for Healthcare Providers • Disease Reporting Requirements for Healthcare Providers • Disease Reporting Requirements for Laboratorians • Disease Surveillance • Epidemiology — Statistics and Reports For more information, call (619) 692-8499 or visit www.sdepi.org.

you take care of the san diego communit y ’s health. legislator birthdays One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday!

we take care of san diego’s

healthcare communit y. 3 income Tax Planning

BIRTHDAY: OCT. 27

3 Wealth Management

State Senator Mark Wyland (District 38) E: (via website) cssrc.us/web/38 E: senator.wyland@sen.ca.gov Sacramento Office: California State Capitol, Rm. 4048, Sacramento, CA 95814 T: (916) 651-4038 • F: (916) 446-7382 Carlsbad Office: 1910 Palomar Point Way, #105, Carlsbad, CA 92008 T: (760) 931-2455 • F: (760) 931-2477

3 employee Benefit Plans 3 Profitability Reviews 3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure 3 succession Planning

BIRTHDAY: NOV. 1

3 Practice Valuations

U.S. Representative Darrell Issa (District 49) E: (via website) issa.house.gov Washington, DC, Office: T: (202) 225-3906 • F: (202) 225-3303 Vista Office: 1800 Thibodo Rd., Ste. #310, Vista, CA 92081 T: (760) 599-5000 • F: (760) 599-1178

WEBSITE SPOTLIGHT

www.SDFighttheBite.com West Nile virus (WNV) is a disease transmitted to humans, birds, horses, and other animals by infected mosquitoes, which get the disease from feeding on infected birds. WNV is established in San Diego County and can be found in all 58 counties in California. The virus, which was first isolated in Uganda in 1937, was detected in the United States in New York City in 1999. From there the virus spread westward, arriving in California in 2003. WNV is now the most prevalent mosquito-borne disease in the United States.

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 ron mitchell, cpa director of health services

RMITCHELL@AKTCPA.COM

Give Us 5 Minutes and We’ll Give You a Benefits Check-up!

Call SDCMS at (858) 565-8888 to schedule a time Today!

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 5

brieflynoted protecting access to quality healthcare

get in touch Your SDCMS and SDCMSF Support Teams Are Here to Help! 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 James.Beaubeaux@SDCMS.org Director of Membership DevelopmenT Janet Lockett at (858) 300-2778 or Janet.Lockett@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 Sonia.Gonzales@SDCMS.org 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 accounting and administrative MANAGER Nathalia Aryani at (858) 300-2789 or Nathalia.Aryani@SDCMS.org

Constitutionality of MICRA Cap on Non-economic Damages Upheld! On Sept. 1, 2011, California’s Fifth District Court of Appeal issued a published decision upholding the constitutionality of the $250,000 non-economic damage cap in California’s landmark Medical Injury Compensation Reform Act (MICRA) of 1975. The case is Stinnett v. Tam. CMA, through its Amicus Curiae Committee, joined in this case by the Litigation Center of AMA and State Medical Societies, filed a friend-of-the-court amicus brief and participated in oral argument before the court. The Stinnett decision is a published opinion and is citable as precedent to oppose plaintiffs’ efforts to introduce evidence with respect to MICRA’s rational basis. The decision also flatly rejects plaintiffs’ arguments that section 3333.2 infringes on their rights to a jury trial or is invalid because it is not indexed for inflation. Visit SDCMS.org for further details. 6 SAN DIEGO PHYSICIAN.org Oc tober 2011

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

SDCMSF Contact Information

5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org

EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Tanya Rovira at (858) 565-8161 or Tanya.Rovira@SDCMS.org RESOURCE DEVELOPMENT DIRECTOR Lauren Banfe at (858) 565-7930 or Lauren.Banfe@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or at Elizabeth.Terrazas@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org

Your Monthly Benefits

check-up Put Your SDCMS-CMA Membership to Work!

This Month:

✓✓ Vital Benefit ✓✓ Seminars & Webinars ✓✓ Physician Advocate Q&A ✓✓ Coding Question ✓✓ Practice Progress ✓✓ Office Manager Advocate Q&A ✓✓ Deadlines & Reminders

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 7

r u o Y y h t Mon l

ts Benefki-up

chec

VITAL BENEFIT for october

Q&A WITH YOUR PHYSICIAN ADVOCATE By Marisol Gonzalez, Your SDCMS Physician Advocate SDCMS member physicians are encouraged to contact Marisol with any practice or membership questions at (858) 300-2783 or at MGonzalez@SDCMS.org.

CMA’s Center for Economic Services Advocacy Request by a Psychiatrist in Private Practice: In the past two to three months, I’ve noticed a marked increase in Anthem Blue Cross’ repeatedly denying payment of psychiatric medications in doses that are above the package insert but well within the standard practice of care. This is a deviation from the past several years when, after explaining medical rationale, an authorization would go through. This is affecting patient care. What can I do? SDCMS-CMA Response: After the physician member provided CMA with copies of the authorization request and denials, the specific medication name and dosage, the condition the physician was prescribing for, and pertinent patient history that demonstrated the clinical decision for the medication dosage, CMA’s Center for Economic Services team got through to Blue Cross’ pharmacy department and got the denials overturned. The physician’s patient also received a written notification about the overturned denial. Members can take advantage of CMA’s Center for Economic Services by contacting Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org.

UPCOMING SDCMS & CMA SEMINARS/WEBINARS Don’t Forget: SDCMS members and their staffs attend free of charge all SDCMS and CMA seminars and webinars. See page 4 for further information.

8 SAN DIEGO PHYSICIAN.org Oc tober 2011

Question: I’m looking for an exam table. Do you know where I can purchase one? Submitted by a dermatologist in solo practice. Answer: SDCMS’ new endorsed partner, STAT Pharmaceuticals Inc., excels at helping small to midsize, office-based physicians and clinics buy their medical supplies, equipment, and pharmaceuticals easier, faster, with better service, and comparably priced to the large, national medical suppliers. SDCMS members receive a 10 percent bottomline savings compared to their current cost on medical supplies and pharmaceuticals. SDCMS members can contact Gene Alley at (619) 956-4200 or at gene@statpharmaceuticals.com. Question: What are physicians liable for with respect to communicable disease reporting to public health? I’m a pediatrician, and we often report pertussis or measles. Are we and the lab individually or collectively responsible for reporting? Submitted by a pediatrician in a medium-size medical group. Answer: According to CMA medical-legal document #1506, “Reporting Communicable Diseases, Including Tuberculosis and Diseases Related to Bioterrorism”: “Every healthcare provider knowing of or in attendance on a case or suspected case of any of the communicable diseases and conditions specified in the regulation [a list of communicable and noncommunicable diseases is included in the CMA medical-legal document] must notify the local health department. If more than one healthcare provider in a healthcare facility, clinic, or other setting may know a case, a suspected case, or the outbreak of a reportable communicable disease, the administrator of the setting must establish administrative procedures to assure that reports are made to the local health department.” According to San Diego County’s Epidemiology Branch, laboratory findings are reportable to the local health officer of the health jurisdiction where the healthcare provider who first submitted the specimen is located within one hour or within one working day from the time that the laboratory notifies that healthcare provider or other person authorized to receive the report. If the laboratory that makes the positive finding received the specimen from another laboratory, the laboratory making the positive finding shall notify the local health officer of the jurisdiction in which the healthcare provider is located within the time specified above from the time the laboratory notifies the referring laboratory that submitted the specimen. If the laboratory is out of state, the California laboratory that receives a report of such findings shall notify the local health officer in the same way as if the finding had been made by the California laboratory. Reading through both the CMA medical-legal document and the information located on San Diego County’s epidemiology website, I believe both the physician and the laboratory have a shared responsibility in reporting communicable diseases.

THIS MONTH’S CODING QUESTION By Michelle Pena, CPC, CHMB (www.cahealth.com) I know ICD-10 doesn’t go into effect until sometime in 2013, but what, if anything, should I be doing to get my practice prepared for this change from CPT to ICD-10? Answer: ICD-10 is scheduled to go into effect Oct. 1, 2013. This change will require considerable modifications to existing information systems (PM and EHR), Electronic Data Interchange (EDI), coding and documentation, workflow processes, and education of clerical and clinical staff. Ramifications of not being prepared will have significant negative effects to compliance and reimbursement, among other factors. To provide some perspective on the enormity of this change: • Current ICD-9 consists of 17,000 codes; ICD-10 will consist of more than 140,000 codes; • ICD-9 is primarily numeric 5-digit codes (some alphanumeric); ICD-10 will be alphanumeric 7-digit codes; • Bottom line: Coding will be a much higher level of specificity, meaning documentation requirements will be significantly increased. From a preparation standpoint, I would recommend reaching out to the following resources — be they internal or outsourced — to ascertain their readiness for ICD-10 and/or their ability to assist you with the transition and change: • CPT and ICD coding; • information system vendors: practice management, EHR, coding, reporting/ business intelligence; • EDI vendors: clearinghouses or direct payer channels (including HMO/managed care entities you send encounter data to; • malpractice carriers and/or brokers you are working with. We highly recommend you contact professional organizations you belong to, such as SDCMS, CMA, and MGMA, for more detailed information and assistance. And, most importantly, START NOW! It will cost you less in heartache and treasure to expect and allow adequate time for staff, physicians, and business partners.

Let us take care of the paperwork so you can take care of your patients. The Perfect Solution... Do you have stacks of insurance applications and contracts to review and complete? Are the endless deadlines and documentation preparation creeping into patient time? At Amador Physician Services, our mission is to ease the burden of healthcare paperwork for administrators, office managers, and physicians alike so you can get back to the business of medicine. With 18 years experience working with the San Diego medical community we are well suited to assist your practice and ease your workload. • Registered in the PECOS system? • Opening a new practice? • Moving? • Adding a physician? • Incorporating? • Inundated with credentialing and recredentialing applications? • Problems with Medicare and Medi-Cal enrollment? We can help! At APS we have assisted numerous San Diego area physicians with these tasks and we can help you, too. Call us today and let us take care of the paperwork so you can take care of your patients.

925.249.9510 info@amadorphysicianservices.com

Give Us 5 Minutes and We’ll Give You a Benefits Check-up!

Call SDCMS at (858) 565-8888 to schedule a time Today!

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 9

r u o Y y h t Mon l

ts Benefki-up

chec

Q&A WITH YOUR OFFICE MANAGER ADVOCATE PRACTICE PROGRESS — ONE MEMBER’S REPORT

Issue updates by individual SDCMS member physicians. The following progress report is submitted by Steven Nottoli, controller for Roxanne Hon, MD. Dr. Hon is board certified in physical medicine and rehabilitation, and has been an SDCMS-CMA member since 2010. Solo practitioners face daily challenges that are both numerous and varied, each usually bringing with it a need for “content expertise, and resource allocation and commitment” — two commodities either in short supply with solo and small-group practices today or completely lacking. Our practice was no different, but our partnership with SDCMSCMA has helped us close existing gaps and add capability, reach, and effectiveness in all areas of our practice and across the entire practice value stream. As a by-product of reengineering our practice, we learned how best to incorporate SDCMS’ and CMA’s support resources, body of knowledge repositories, and key program initiatives into the framework of our updated business model and practice management structure. We have gained economies in areas not seen before, and, through participation in SDCMS’ seminars and engagement with CMA’s Center for Economic Services, we have significantly improved our revenue cycle management efforts. We have accomplished this with the use and adoption of CMA’s Best Practices, Back to Basics, and Taking Charge publications, allowing us to create and sustain a balanced scorecard for our practice. Beyond the tactical elements of our practice, it has become increasingly clear as well that large and profitable insurance/payer systems of seemingly unconstrained resources have created and are designing their business strategies and processes to leverage/exploit the very apparent knowledge and resource limits that solo and small-group practices have today. Without question, partnering with SDCMS-CMA has become a welcome equalizer and even force-multiplier in our fight to try and ensure equitable treatment by such entities. We hope all physicians — not just solo and small groups — recognize the value of SDCMS-CMA membership as we have. There is strength in numbers.

10 SAN DIEGO PHYSICIAN.org Oc tober 2011

By Sonia Gonzales, Your SDCMS Office Manager Advocate Office managers of SDCMS member physicians are encouraged to reach out to Sonia — THINK SDCMS FIRST! — when you have a question or issue you need help with. Contact Sonia at (858) 300-2782 or at Sonia.Gonzales@SDCMS.org. Question: What do I do if I receive an overpayment request letter from a health plan’s “special investigations unit”? Submitted by a solo gastroenterology practice’s billing manager. Answer: Request itemization of the payments in question because they (the health plans) must clearly identify the name of the patient, date of service, amount of the overpayment, and a clear explanation why the payer believes the amount paid on the claim was in excess of the amount due [28 C.C.R. §1300.71 (d)(3) and Insurance Code 10133.66(b)]. Review the rationale for the request for overpayment, and research its accuracy. Make sure you check the plan’s website and/or provider manual to confirm whether the plan has a published payment or medical policy on the topic. Perform an internal audit to verify that your practice actually received payment from the plan. Identify whether the overpayment demand was requested in a timely manner because managed care plans may seek recovery of an overpayment within 365 days of the date of payment — the 365-day limit does not apply if the overpayment was caused in whole or in part by provider fraud or misrepresentation [28 C.C.R. § 1300.71 (b)(5) and Insurance Code §10133.66(b)]. Identify whether there are any replacement codes that would be appropriate that could lower the overpayment amount. If you disagree with the overpayment request, dispute the request in writing within 30 working days. And finally, make sure you open a dialogue with the auditor. For more information, CMA has published the “Special Investigations Unit Audit Guide,” available free to members. Please contact me, Sonia Gonzales, at Sonia.Gonzales@SDCMS.org or at (858) 300-2782.

Question: Is it OK to charge patients for missed appointments? Submitted by the office manager of a solo-physician pediatric office. Answer: Unless a physician has entered into a contract with a payer that prohibits such charges, a physician may charge a patient when he or she misses an appointment or does not cancel in adequate time to allow another patient to fill the appointment slot — if advance notice of such a billing policy is given. Specific billing rules may also apply with regard to certain payers (e.g., Medi-Cal and Medicare). For more information about billing patients for missed appointments, see CMA medical-legal document #0110, “Billing Patients.”

PRACTICE MANAGEMENT AND MEMBERSHIP DEADLINES & REMINDERS • ONGOING: TDC-insured SDCMS member physicians MUST satisfy their participation requirement ONCE EVERY TWO YEARS to continue receiving their TDC medical professional liability insurance premium credit. Contact Janet Lockett at SDCMS at (858) 300-2778 or at Janet.Lockett@SDCMS.org. • NOV. 1: $50 Early Bird Dues Discount Deadline • DEC. 31: Reporting year ends for eligible professionals (eRx). • JAN. 1: $100 Three-year Commitment SDCMS-CMA Dues Discount Deadline • JAN. 1: SDCMS-CMA Membership Dues Deadline • JAN. 1: 4010 TRANSACTIONS WILL BE NONCOMPLIANT AND REJECTED! On Jan. 1, 2012, the HIPAA 5010 standard will go into effect. This affects all of the HIPAA Standard Transactions, including the following pertinent transactions for most medical practices: electronic claims; electronic remittance advices; electronic requests for eligibility and benefit verification and the responses; electronic referral authorizations; and electronic claims status. The last major change was in October 2003, when the HIPAA transactions and code sets rule took effect. The 5010 changes reduce ambiguity in many of the transactions and provide some very important new codes, such as ICD-10. They also eliminate many of the situational codes while implementing requirements such as taxonomy codes on all claims. Medical practices should be preparing now for this change by ensuring your vendors (billing software, billing services, and clearinghouses) are ready and that your software is capable of generating a 5010 transaction. If your practice management systems are not compliant with HIPAA Version 5010 standards by Jan. 1, 2012, you will risk not getting electronic payments from Medicare or private insurers. • FEB. 29: Last day for eligible professionals to register and attest to receive incentive payment for calendar year 2011 (eHR).

KolAH lAw HelPS ClientS meet the growing challenges oF tHe HeAltHCAre inDuStry. We take the time to understand your legal issues, values and goals, and offer a variety of legal options to protect your interests while promoting success in your practice. We advise and represent clients in a range of health care legal areas including:

AnAheetA Z. KolAh

• Lobbying for the Healthcare Industry, State & Federal • Compliance • Regulations • Reimbursement • Business Transactions • Corporate Governance • Alternate Dispute Resolution • Patient Care • Estate Planning / Asset Protection

4370 la Jolla Village Drive Ste 400 San Diego, CA, 92122 Phone: (858) 546-4480 Fax: (858) 546-4482 kolahlaw@lawfirmofsandiego.com www.lawfirmofsandiego.com

MAS in HeAltH lAw

TODAY’S HEALTHCARE ATTORNEY FOR TOMORROW’S HEALTHCARE PROFESSIONAL.

Give Us 5 Minutes and We’ll Give You a Benefits Check-up!

Call SDCMS at (858) 565-8888 to schedule a time Today!

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 11

Disaster Preparedness

The Great Southern California Blackout of 2011 10 Lessons Learned by Tom Gehring

12 SAN DIEGO PHYSICIAN.org Oc tober 2011

The blackout that affected more than 3 million people across southernmost California and into Arizona and Baja California on September 8 caught us all off guard. Below are my observations as CEO of SDCMS, chair of the San Diego and Imperial counties chapter of the American Red Cross, and as a private citizen. Please feel free to email me your own observations — Gehring@SDCMS.org — so that we may benefit as a community and better prepare ourselves and our families for any such future events. » 1. There was zero warning. None. So, as we used to say in the submarine business, it was a “come as you are war” — you need to be ready all the time. Ditto for earthquakes. Fires and hurricanes give you time to prepare, but not so here. 2. You should do a zero-based assessment of your power systems, as in, what would happen to you if the lights went out and stayed out. a. What has a backup power supply (sometimes referred to as “uninterruptible power supply” or UPS) connected to it?

b. Does your computer shut down automatically when the UPS says “almost out of battery power”? That option is relatively easy to set up with most state-of-the-art UPSs. And an uncontrolled shutdown is just that, a disaster looking for a place to happen … can you say “blue screen of death”? c. How will you start the computer back up when the lights go back on? Remotely? In person? Who? How? Etc. d. What happens when your alarm system runs out of power? e. Do you test your backup systems? How often? When was the last “end-toend test” of your “we don’t have any power” plan? f. Do you have a phone system that does not require 110 volts? FYI, phones were originally designed to be independent of line voltage, and they still work fine with no 110 volt, but you need one of those “oh so yesterday” analog phones. Ditto fax. g. Where’s your membership data? Could you access it if your server is down? We at SDCMS keep a SECURE (let me emphasize that, SECURE) USB “dongle” disk drive with the entire database of San Diego County physicians, but it’s two-factor encrypted (need to know two passwords and have a gizmo) so that its inadvertent loss would not cause your name to be in the papers. 3. What happens to critical systems when the lights go out? a. Cell phone towers actually worked amazingly well for our 12-hour-plus outage. Probably the batteries would have died had it gone much longer, but I had cellular connectivity the whole time, BUT … b. How many spare cell phone batteries do you have (I had one and am buying another two)? c. Ditto spare batteries for your laptop. I always run around with a spare sevenhour battery. d. Cell phone texting worked better than cell phone voice. e. Cars are a wonderful source of power. Do you have a 12 volt DC upconverter to 110 volt AC? I was amazed at the number of people sitting in cars with

the engine running going nowhere but charging stuff or (and I wish were kidding about this) listening to their radio, but see 5.a. f. For those in charge of large systems with external power generators, when was the last time you really “stress tested” your generator? At least one hospital was really embarrassed when their shiny new generator ran for a while then quit. Bad PR. g. And speaking of generators, consider a handy dandy little generator for “lowpower” items — see 3a and b above and 6 below. Alternatively, you could get one of those hand-crank generators that do the same thing with elbow grease. 4. Do you have a battery-powered radio? So “yesterday” but, guess what, we didn’t, and so we had no clue what was happening. We were able to connect to the Internet via battery-powered systems, and at least one TV station was streaming to the Internet (as opposed to transmitting over the airwaves), and they were a good source of news. After the fact, we figured out that we actually DID have an FM radio — my iPod clone had the capability — we just forgot about it. 5. On a personal note: a. Gas pumps don’t work without power (duh), so do the thing every good Navy destroyer skipper did: Never ever let gas go below 50 percent (see note 1). b. ATMs don’t work without power (duh), so how much cash do you have stashed away? How about in the office if you needed to pay for stuff and credit cards were not accepted? c. While I don’t usually wear high heels (just don’t look good in ’em), for folks who wear really uncomfortable shoes, you might consider keeping a pair of walking shoes in the trunk of your car. Never know when you might have to walk your way home or off the freeway! d. Candles really work well (and I wonder what will happen in nine and a half months? ;-), but a copious supply of flashlights and a trunk-load of AA batteries are really nice. e. Got water? How much? There were

parts of San Diego that were under a “boil water” alert. f. Got food? How much? Didn’t turn out to be a problem because the lights came on in under 24 hours. But what if they hadn’t? g. And speaking of boiling, that gas-powered barbecue is a surprisingly handy “no power” device. Matches/lighter sticks are mandatory if you want to light a range with no electricity. 6. While there is no sure thing, I was amazed that the Internet providers (DSL and cable) worked IF AND ONLY IF you had 110 volt power that supplied the modem/router. And modems/routers don’t use a lot of power, so I actually purchased a second UPS at home to separately power up my router, modem, phone, and laptop (all low-power users). 7. Satellites don’t care about 110 volt, so we are asking ourselves, what can we get off a satellite? We are considering buying a SAT phone and a satellite-based pager. Pagers … are you kidding? That’s so “yesterday”! Yeah, but two-directional text messaging through satellites worked really well. 8. Do you have a disaster plan for home and work? 9. What’s your plan for manning the office in case of a sustained loss of power? One answer is, “Well no, we’re just going to sit at home.” But for large offices, that may not be an answer. So have you thought about who would man the office, for how long, etc.? And how do you keep from having everyone show up for the first 12 hours, and no one for the next 36? 10. How will you get the word out? What happens if you absolutely cannot? Do you have a plan that allows someone who does have power to get something out? Please feel free to email any additional observations to Gehring@SDCMS.org. I’ve now participated in three major disasters as CEO — the anthrax scare in 2001 and the San Diego wildfires of 2003 and 2007 — so it’s really not a question of whether, but when! Mr. Gehring is executive director and CEO of the San Diego County Medical Society. Oc tob er 2011 SAN DIEGO PHYSICIAN.org 13

Physician Workforce

The Total Economic Impact of Physicians in San Diego County

$5.4 Billion – $7.6 Billion 14 SAN DIEGO PHYSICIAN.org Oc tober 2011

by Tom Gehring and Thomas Chippendale

tracted from the calculation are 858 physicians with incomplete data sets or physicians who appear to represent physician employees in academia, internship and training programs, pharmaceutical/industry positions, physician scientists, and other administrators. Thus, using mode of practice data from the SDCMS database as verification, there are an estimated 3,515 independent solo and small-group practitioners actively seeing patients in San Diego County (See figure 1).

The total economic contribution of physicians in San Diego County ranges from $5.4 billion to $7.6 billion.

The TEA of Office-based Physicians Once the office-based physicians have been counted, their total economic activity can be projected. This calculation relies heavily on the February 2011 American Medical Association report, “The State-Level Economic Impact of Office-Based Physicians,” which described and measured the total economic activity of physicians at both the state and national levels. The direct impact of an officebased physician includes the output, jobs, wages, benefits, and taxes produced from providing patient care (1). The indirect Solo andimpact Small-group is determined by calculating the Physicians output, jobs, wages, benefits, and taxes of Large-group Physicians the industries supported by office-based Hospital-based Physicians physicians (2). The latter is an “economic Physicians > 75 that accounts for the ways Years of multiplier” Age overhead of an office-based physician Military /the Government Physicians can be spent more than once. The total Physicians With Administrative Positionsactivity is the sum of the direct economic

Figure 1

3,515

Miscellaneous Physicians

(e.g., Academic, Pharma, Physician Scientists, Other Administrative)

2,235

Solo and Small-group Physicians Large-group Physicians

1,213

Hospital-based Physicians

3,515

319

ber of Physicians in San Diego County

Method 1: Counting the Office-based Physicians Estimates of the economic impact of a specific population must rely on assump-

tions. Such is the case with an analysis of the economic contribution made by officebased physicians. According to the San Diego County Medical Society (SDCMS) database, there are 8,505 physicians with a valid license in San Diego County. To determine the fraction of these doctors who are independent solo or small-group office-based physicians, we must remove a number of categories from that overall physician cohort: • The 2,235 physicians identified in the SDCMS database who are employed by large groups such as Scripps Clinic Medical Group, Sharp Rees-Stealy Medical Group, Southern California Permanente Medical Group, the University of California San Diego, Children’s Specialists of San Diego, and other employee or foundation-model physicians. • The 1,213 radiologists, anesthesiologists, pathologists, hospitalists, and emergency medicine physicians are presumed to have hospital-based practices and are therefore not solo or small-group, officebased physicians. • Physicians over age 75 are excluded, as they are presumed to be retired. The study recognizes that there may be doctors over 75 still practicing, but the study assumes that they are balanced by physicians under 75 who are not practicing, despite an active license. • There are 365 physicians who self-identified as being exclusively in military/ government or administrative positions, and are presumed not to be in officebased practices. • Another miscellaneous category sub-

Number of Physicians in San Diego County

Executive Summary Beyond the medical care they render, which enables our workforce to remain active, doctors play a vital role in the U.S. economy through the jobs and vendors they support, the taxes they pay, and the wages they earn and spend. This study quantifies the total economic activity (TEA) of physicians in San Diego County. Two methods were used to determine the TEA of San Diego County’s doctors. Method 1 divided the physician population into those with office-based practices and those with non-office-based practices (in either large groups or based in hospitals). For office-based practices, we used the American Medical Association study that determined the average TEA of office-based practices, multiplied this average TEA by the number of office-based doctors, and adjusted for those physicians not working full-time. For those physicians not practicing in independent, office-based settings, we multiplied the number of doctors, adjusted for those not working full-time, by the average salary to determine TEA. • The approximately 3,500 independent, office-based San Diego County physicians contribute about $6.7 billion to the local economy. • Another approximately 4,600 physicians practicing in large groups, hospitals, or in administrative positions contribute about $950 million to the San Diego County economy. Method 1 determined that physicians in San Diego County contribute no less than $7.6 billion to the local economy. Method 2 uses a simple ratio: It takes the total dollars spent on healthcare in the United States, ratios that number based on the population of San Diego County versus the national population (about 1 percent), and determines what percentage of the San Diego County healthcare dollar is attributed to doctors (20 percent). Method 2 determined that doctors in San Diego County contribute approximately $5.4 billion to the San Diego County economy. The total economic contribution of physicians in San Diego County ranges from $5.4 billion to $7.6 billion.

858

Physicians > 75 Years of Age Military / Government Physicians

315

Physicians With Administrative Positions

Miscellaneous Physicians

(e.g., Academic, Pharma, Physician Scientists, Other Administrative)

2,235

Physician Cohorts

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 15 1,213

Physician Workforce and indirect effects. The key finding in the AMA report, as it relates to this study, is the “total value per physician” at the national level. On average each physician in the United States produced $2.2 million in economic activity. This number includes the combined direct and indirect economic effects. Using this as a primary source, and assuming the average “value” attributed to U.S. physicians reasonably estimates that attributable to San Diego County physicians, the number of independent solo and smallgroup office-based physicians in San Diego County can be multiplied by the economic activity of the average U.S. physician to reach the total economic activity at the county level. The TEA for San Diego County solo and small-group office-based physicians is $7.7 billion (3,515 x $2.2 million = $7.733 billion). Counting the Total Economic Activity of Hospital-based Physicians To calculate the impact of non-office-based

physicians, we have to first determine the number of non-office-based physicians. To do so, we subtract the number of officebased physicians (3,515) and retired physicians (319) from the total number of active licenses in San Diego County, or 8,505 minus 319 minus 3,515, or 4,671. Given that these non-office-based physicians have their overhead and other economic impacts counted by other groups (for example, a physician at Kaiser or a radiologist at Grossmont Hospital has economic activities that are counted by either Kaiser or Grossmont), we will conservatively assume that the only economic impact would be the salaries of the physicians. The TEA of hospital-based and largegroup doctors is determined by multiplying 4,671 non-office-based physicians by the average physician reimbursement as determined by SDCMS ($239,567) to give a total of $1.1 billion. It is important to note that the $1.1 billion is by definition on the conservative (low) end of the actual impact, as there aren’t any studies that

articulate the total economic activity as clearly as for office-based physicians. So only using the salaries, without adding the myriad other economic activities that are presumed to be included in the hospital accounting, while more conservative, actually undercounts the TEA. Correcting for FTEs Not all physicians are working full-time, so our TEA analysis must be adjusted accordingly. The California Healthcare Foundation in its July 2010 report titled, “The California Healthcare Almanac: California Physician Facts and Figures,” provided the percentage of physicians that work the hours of six categories ranging from zero to over 40 hours a week (0, 1–9, 10–19, 20–29, 30–39, 40+) (3). Each of the cohorts was assumed to represent its median number (i.e., the physicians working 1–9 hours were assumed to all be working five hours per week), and the category 40+ hours was assumed to represent 45 hours. An FTE of 1.0 was chosen to represent 40 hours a

New Class “a” mediCal offiCe spaCe foR lease > 1,200 - 40,000 sf

4S RANCH MEDICAL PLAZA

NW CORNER OF CAMINO DEL NORTE & DOVE CANYON ROAD

Introducing an outstanding opportunity to practice in an untapped high growth & desirable community.

Exclusively represented by: PAUL BRAUN 858.677.5324 paul.braun@colliers.com LIC.NO. 00891709

16 SAN DIEGO PHYSICIAN.org Oc tober 2011

CHRIS ROSS 858.677.5329 chris.ross@colliers.com LIC.NO. 01469025

COLLIERS INTERNATIONAL 4660 La Jolla Village Drive, Suite 100 San Diego, CA 92122 858.455.1515 www.colliers.com/sandiego

week. A weighted average was calculated, resulting in an FTE correction factor of 0.87. The TEA must be adjusted from $8.8 billion ($7.7 billion + $1.1 billion) to $7.7 billion (0.87 x $8.8 billion). Using Method 1, the TEA of all San Diego County doctors is $7.7 billion. Method 2 To provide a range and context for this total, another method of calculating the economic activity of doctors should be considered. The California Health Care Foundation provided statistics regarding the national healthcare economy in its 2009 report, “California Health Care Almanac: Health Care Costs 101.” • This report gives a total for national healthcare spending at $2.5 trillion for the year 2009, and a projected $2.7 trillion for 2011 (4). • An estimated 20 percent of this 2011 total is attributed to physician services (5), giving a 2011 total of $540 billion. • Since the population of San Diego County (3.1 million) (6) is 1 percent of

the national population (308 million) (7), the healthcare spending created by physicians in San Diego County can be estimated at 1 percent of $540 billion, or an estimated $5.4 billion. Using method 2, the total economic impact of physicians in San Diego County is $5.4 billion. The Big Picture Whether the total economic activity of independent office-based physicians is indeed closer to the $7.7 billion or the $5.4 billion figure is clearly debatable. What is important is that the estimates have been compiled and that hopefully the real number, whatever it may be, is captured between a high and low approximation. Regardless, the economic contribution of this subset of physicians is significant to the welfare of San Diego County and cannot be overlooked. Mr. Gehring is CEO and executive director of the San Diego County Medical Society. Mr. Chippendale, who worked as an intern for

SDCMS during the summer of 2011, is the son of Dr. Thomas J. Chippendale, SDCMS-CMA member since 2004. Notes: 1. The State-Level Economic Impact of OfficeBased physicians. The American Medical Association, February 2011, page 1. 2. The State-Level Economic Impact of OfficeBased physicians. The American Medical Association, February 2011, page 9. 3. California Healthcare Almanac: California Physician Facts and Figures. The California Healthcare Foundation, July 2010, page 4. 4. California Health Care Almanac: Health Care Costs 101. The California Healthcare Foundation, 2011, page 3. 5. California Health Care Almanac: Health Care Costs 101. The California Healthcare Foundation, 2011, page 8. 6. Elizabeth Aguilera and Lori Weisberg, “Last Decade of Growth in County Was Slowest Ever,” The San Diego Union-Tribune, March 8, 2011. 7. “U.S. Census Bureau Announces 2010 Census Population Counts — Apportionment Counts Delivered to President,” U.S. Census Bureau, December 21, 2010.

New Class “a” mediCal offiCe spaCe foR lease > 1,000 - 30,000 sf

PACIFIC MEDICAL PLAZA

4910 DIRECTORS PLACE, SAN DIEGO, CA 92121

The Golden Triangle’s newest medical office building. Offering convenience, easy access, warm & healing environment and cost savings. Home of the new Surgical Center of San Diego and other noteworthy tenants. Exclusively represented by: PAUL BRAUN 858.677.5324 paul.braun@colliers.com LIC.NO. 00891709

CHRIS ROSS 858.677.5329 chris.ross@colliers.com LIC.NO. 01469025

COLLIERS INTERNATIONAL 4660 La Jolla Village Drive, Suite 100 San Diego, CA 92122 858.455.1515 www.colliers.com/sandiego

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 17

public health Practicing physicians are mandated to report a number of conditions to their local Department of Health Services (DHS); the list of reportable conditions in California has been recently updated and can be found at www.cdph.ca.gov/HealthInfo/ Pages/ReportableDiseases.aspx. Compliance is less than ideal, despite potential sanctions against physicians for not reporting. Of importance to note is that some of the conditions must be reported within the hour of diagnosis, others within a day, and the rest within a week. Guidance is provided by the icons (phone, fax, etc.) that precede the diagnosis on the list. In San Diego County, www.sdepi.org provides the listing of reportable diseases, as well as forms for communicable and noncommunicable diseases, and a separate form for tuberculosis use. Do not assume that your laboratory will report for you; it remains the responsibility of the physician to report these diseases to the County. The DHS would rather have duplicates than lapses in reporting. The noninfectious diseases that must be reported to DHS include lapses of consciousness, cancers, and pesticide-related illnesses. Lead poisoning is reported by laboratories, but DHS would welcome physician reporting as well. Compliance with reporting of noncommunicable disease has been even more problematic. This is at least partially due to the impaired understanding of the mandate and (unfounded) concerns about the protections afforded to reporting physicians. The California Department of Motor Vehicles’ (DMV) reporting requirement, “every patient 14 years of age or older, when a physician and surgeon has diagnosed a disorder characterized by lapses of consciousness in a patient,” (dmv.ca.gov/ pubs/vctop/appndxa/hlthsaf/hs103900. htm) Title 17, section 2806, describes lapses of consciousness (LOC) as those conditions that involve: • marked reduction of alertness or responsiveness to external stimuli • inability to perform one or more activities of daily living, or • impaired sensory motor functions used to operate a motor vehicle. Examples of these conditions include: • loss of consciousness (e.g., syncope, hypoglycemia) 18 SAN DIEGO PHYSICIAN.org Oc tober 2011

Mandated Disease Reporting Requirements A Roadmap By Linda Louise Hill, MD, MPH

• seizures • dementia, including Alzheimer’s disease and other dementias (e.g., postCVA, brain neoplasm) • conditions such as sleep apnea and narcolepsy where they interfere with driving. Physicians are protected from liability with good-faith reporting for these and other conditions they feel interfere with safe driving. In fact, physicians have had judgments against them for failure to report when drivers with these conditions had subsequent motor vehicle crashes. Physicians do not need to report former drivers who are unlikely to drive again (admitted to long-term care facility, severely impaired, coma, etc.), or when there is documentation in the chart that the patient has been reported previously and you believe they no longer operate a motor vehicle. As stated above, to report lapses of consciousness to the DHS, the form for noncommunicable diseases can also be found at www.sdepi.org. The reported cases of lapses of consciousness are forwarded by the DHS to the DMV; however, simultaneous direct reporting to the DMV will result in timelier follow-up by the DMV. To report directly to the DMV, it is best to use the DMV’s Request for Driver Reexamination (DS699), which can be found at: dmv. ca.gov/forms/ds/ds699.pdf, but faxing the CMR form, or even using office letterhead, is acceptable. Lapses in consciousness should be reported only when associated with an event in a patient who has an underlying condition likely to impair driving. Therefore, while a loss of consciousness due to diabetes-associated hypoglycemia is reportable, the loss of consciousness from an injury-induced mild concussion is not. Narcolepsy associated with somnolence during driving is reportable, but recumbent-only associated sleep apnea is not. Even mild dementia is reportable, but confusion post-operative is not. The development of a reporting system and written protocols will improve compliance in your institution. The physician making the diagnosis is responsible for the reporting, whether in the emergency department or office. However, do not assume that another physician has reported,

unless there is written documentation in the chart. Again, the DHS and DMV would rather have duplicate reporting than none at all. For example, if your epileptic patient had a seizure, was brought to the emergency department, and follows up with you the next week, you should report the incident if you don’t see documentation of reporting in the emergency department records. Similarly, if a patient with dementia transfers to your care, you must report them to the DHS unless the prior records reflect notification in your state. As mandated reporters, we are required to report lapses of consciousness, but we can reassure our patients that this does not equal the loss of one’s driving privilege, as only the DMV is authorized to make this determination. The DMV wants to hear about all reportable LOC, but makes a decision on each driver after conducting a thorough investigation that will include additional medical information, usually obtained through DMV form DS 326 (dmv.ca.gov/forms/ds/ds326.pdf), and may include interviews, vision and written exams, and on-the-road testing. In patients with mild dementia, for example, the DMV may determine that they are safe to continue driving for an abbreviated period of time, with close monitoring. Identification of age-related driving disorders (see May 2010 San Diego Physician) includes the screening and diagnosis of lapses of consciousness, frailty, vision deficits, and other medical conditions (e.g., use of medications that impair cognition) that influence driving abilities. AMA has provided guidelines for screening at www. ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/ assessing-counseling-older-drivers.page. Of the disorders identified through this screening, only lapses of consciousness require reporting. Keeping our patients and the public safe requires attention to driving safety, including compliance with noncommunicable-disease mandated reporting laws. Dr. Hill, SDCMS-CMA member since 2010, is a clinical professor in the Department of Family and Preventive Medicine at UCSD, and the director of the UCSD/SDSU General Preventive Medicine Residency. Oc tob er 2011 SAN DIEGO PHYSICIAN.org 19

Infectious Disease

Gastroenteritis Caused by

Noroviruses

An Update on This Highly Infective Pathogen By Robert E. Peters, PhD, MD

20 SAN DIEGO PHYSICIAN.org Oc tober 2011

Studies have confirmed that preexisting antibodies in challenged volunteers do not always convey immunity.

Note: To read this article with complete references, please visit SDCMS.org.

pigs and dogs may add new perspective to this reservoir question.

Noroviruses, previously referred to as “Norwalk virus,” are one of the most common, if not the most common, causes of gastroenteritis worldwide — the source of more than 50 percent of all outbreaks. In the United States, approximately 21 million cases of gastroenteritis are attributable to norovirus annually. Norviruses cause approximately 35 percent of cases of sporadic gastroenteritis of known cause, 5–31 percent of patients hospitalized for gastroenteritis, and in the range of 5–36 percent of clinic visits by patients who present with gastroenteritis. Norovirus infections are believed to be significantly under-diagnosed and under-reported. The CDC reports that of total patients presenting with gastroenteritis, only one in approximately 1,500 is specifically diagnosed as to the causative agent. Of the approximately 21 million GI illnesses mentioned above, one quarter are attributed to foodborne transmission. A systematic review of 31 community, outpatient, and hospital-based studies in both developed and developing countries estimates that norovirus accounts for 10–15 percent of the severe gastroenteritis cases presenting in children 5 years old and younger, and 9–15 percent of mild and moderate diarrhea cases presenting among patients of all ages. Outbreaks of gastroenteritis occur throughout the year. There is, however, a seasonal pattern with increased incidence observed during the winter months. In addition, periodic increases in norovirus outbreaks tend to occur in association with the emergence of new GII.4 strains. These new strains tend to evade population immunity and rapidly replace existing prior strains that had dominated in circulation. Emergence of a new strain or strains can result in an unusually high norovirus activity during a given year. Of significant relevance to physicians, noroviruses have been confirmed to replicate only in the gastrointestinal tract. Many investigators have suggested that humans are the primary if not the only reservoir for these viruses; however, recent studies confirming strains identified in

What Are Noroviruses? Noroviruses are a group of nonenveloped, single-stranded RNA viruses. These viruses are classified into the genus Norovirus (previously referred to as Norwalk-like viruses or small, round-structured viruses) of the family Caliciviridae. Noroviruses can be divided into at least five genogroups, designated GI–GV, based on the amino acid sequence identity in the major structural protein VP1. Strains that infect humans are found in the GI, GII, and GIV genogroups. Strains that infect pigs are found in the GII group, and a norovirus of the GIV group has recently been reported as a cause of diarrhea in dogs. Interspecies transmission has not been documented, but the potential for zoonotic transmission exists. On the basis of the noroviruses’ having more than an 85 percent sequence homology in the complete VP1 genome, these noroviruses can be further classified into genotypes within the genogroups. At least eight genotypes comprise the GI genogroup, and 21 genotypes fit within the GII genogroup. GII.4 genogroup viruses have been associated with the majority of human viralbased gastroenteritis outbreaks worldwide. Recent studies confirm that these viruses evolve over time, primarily through serial changes in the VP1 sequence, by which there is an evasion of any established immunity (human).

What Do We Know About Immunity? Several questions remain unanswered regarding immunity. Protective immunity to norovirus is a complex and not fully understood mechanism. Studies have confirmed that preexisting antibodies in challenged volunteers do not always convey immunity. That noted, in those studies some subjects have remained uninfected despite significant purposed exposure to the pathogen. Both innate host factors and acquired immunity are hypothesized to contribute to an individual’s susceptibility to infection. Evidence also suggests that recently described GII.4 genogroup variants evolve to escape acquired immunity

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 21

Infectious Disease

in humans. Norvirus undergoes antigenic shift and drift similar to what has been observed for influenza-causing viruses. A change in the viral capsid of the virus alters the binding of the virus to certain GI tract oligosaccharides. The arrival of a new variant (or variants) appears to drive a new epidemic wave, and new pandemic strains appear to occur every two to four years.

Who Are the At-risk Groups, and How Is the Norovirus Expressed?

Humans have been, and are, the only known reservoir for the relevant infective strains determined to date to be human pathogens.

Noroviruses cause acute gastroenteritis in all ages. Illness begins after an incubation period of 12–48 hours, typically characterized by acute onset, non-bloody diarrhea, vomiting, nausea, and abdominal cramps. Some infections are characterized by vomiting or diarrhea only. Low-grade fever and body aches can be associated with infection, which may result in an inappropriate diagnosis of “stomach flu.” Norovirus symptoms are usually self-limiting and resolve without treatment after one to three days in otherwise healthy individuals. More prolonged illness, four to six days, can occur in at-risk groups, which include younger children and elderly individuals — including residents of skilled nursing facilities and hospitalized patients. Medical care is supportive, which includes treatment for dehydration with oral or intravenous fluids. Ill members are requested not to do food prep during course of illness.

Transmission Norovirus is shed primarily in the stool. It can also be found in the vomitus of infected persons. The virus can be detected in the stool for an average of four weeks following infection, although peak viral shedding occurs two to five days after infection. Viral load will typically be approximately 100 billion viral copies per gram of feces. It should be noted that some investigators suggest that it is unclear that detection of virus alone indicates a risk of transmission from the given subject. An inability to culture these viruses, and non-availability of an animal model, have hampered the ability to determine how long the viruses remain infectious after being expelled, and also at which point the

22 SAN DIEGO PHYSICIAN.org Oc tober 2011

patient is no longer contagious. Furthermore, estimates are that up to 30 percent of patients with norovirus infection are asymptomatic, and it has been confirmed that asymptomatic individuals can shed virus for up to eight weeks, albeit at lower titers. At this time the role that asymptomatically infected individuals may play in transmission and in epidemic outbreaks remains unclear. Norovirus is extremely contagious. Infectious dose has been estimated to be as low as 18 viral particles with the suggestion that something like 5 billion infectious doses may be contained in each gram of feces during peak shedding. Humans have been, and are, the only known reservoir for the relevant infective strains determined to date to be human pathogens. Transmission occurs by three general routes: personto-person, foodborne, and waterborne. Person-to-person transmission can occur directly through the fecal-oral route or by ingestion of aerosolized vomitus or by exposure via fomites or contaminated environmental surfaces. Food can become contaminated with norovirus at any point during production, processing, distribution, and preparation. A variety of products have been implicated in outbreaks. Foods eaten raw (e.g., leafy vegetables, fruits, and shellfish) are among the most commonly identified contaminated foods. Norovirus outbreaks have resulted from fecal contamination of certain food products at the source. Oysters have been identified as transmission sources when harvested from fecal-contaminated growing waters. Raspberries irrigated with sewage-contaminated water have been identified as pathogen sources. Contamination of foodstuffs with norovirus can also occur during commercial food processing, as demonstrated by a recent outbreak involving delicatessen meat. Because such a minimal dose of virus can result in infection, an infected food handler can potentially contaminate large quantities of end product. Finally, both drinking water and “recreational” water can serve as vehicles of norovirus transmission, causing large outbreaks in a given community. These outbreaks have included well water that had become contaminated from septic

John O. Johnson, MD

Imaging Healthcare Specialists: The Low Radiation Dose Leader How do we measure radiation risk? • The unit of measurement used to estimate radiation exposure is the millisievert (mSv) • Annual unavoidable background radiation is 3 mSv • Experts estimate an incremental 0.1% increased cancer risk for each 10 mSv of exposure • Chest x-ray: 0.1 mSv = 10 days of background • CT of the abdomen: 10 mSv = 3 years of background

Imaging Healthcare Specialists is the leader in low radiation dose initiatives to ensure our patients’ safety, health, and well-being. We are committed to limiting the use of radiation for our patients through the practice of ALARA (As Low As Reasonably Achievable). Under the leadership of radiologist, Dr. John O. Johnson, Imaging Healthcare Specialists has optimized its’ CT imaging protocols to ensure we are using the least amount of radiation necessary to acquire a diagnostic quality examination for each patient.

• An estimated 70 million CT scans are performed annually in the United States

• Approximately 1 in 5 adults will receive a CT scan each year

• Low dose CT protocols can reduce radiation exposure in the average patient by as much as 75%

For more information on Imaging Healthcare Specialists’ low dose initiatives, visit imaginghealthcare.com

T E M E C U L A VA L L E Y

OCEANSIDE

E N C I N I TA S

P O WAY

LA JOLLA

SAN DIEGO

C H U L A V I S TA

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 23

Infectious Disease

tank leakage and failure of proper chlorination of municipal water systems.

Where Do We See Norovirus Outbreaks? Because the virus can be transmitted by an infected individual, by food and water, and by contaminated environmental surfaces, preventing and managing outbreaks can be problematic. Given that there appears to be no long-lasting immunity to norovirus by the individual, outbreaks can occur in a variety of institutional settings (e.g., nursing homes, hospitals, schools, child care centers, colleges, prisons, military encampments, restaurants, and catered events). Passengers and crew aboard cruise ships have been implicated in norovirus outbreaks during “at-sea” periods. In these cases, virus has generally been introduced on board by either passengers or crew infected prior to embarkation. However, food items contaminated and loaded into the ship’s stores or persistently contaminated environmental surfaces (previous cruises) may also be sources of the pathogen.

Diagnosis and Detection Norvirus is not culturable in the clinical lab. Detection by methods such as enzyme immunoassay (EIA) is relatively inexpensive but limited in sensitivity. Some question how broadly reactive an EIA may be, given the antigenically distinct norovirus strains that appear. At this time virology laboratories tend to perform real-time, reverse transcriptionpolymerase chain reaction (RT-PCR) assays for norovirus detection. This method has been in use since the 1990s and is considered the “gold standard” for norovirus detection. However, this is a relatively expensive diagnostic test procedure, and it requires specimens such as whole stool, rectal swabs, or vomitus obtained during acute phase of illness (within 48–72 hours of diarrhea onset). The specimen can be kept refrigerated at 4°C for up to two to three weeks without compromising diagnostic yield, or frozen if it cannot be shipped to a lab within three weeks. The increased sensitivity of molecular assays often allows the virus to be detected in stools collected up to seven to 10 days after onset. Individual cases of norovirus are not

24 SAN DIEGO PHYSICIAN.org Oc tober 2011

specified to be nationally notifiable by the respective treating physician. However, outbreaks of acute gastroenteritis among higher numbers of an identified population should be reported to the appropriate local or state health departments, in accordance with local regulations. A norovirus outbreak specimen submittal form is sent along with specimens for laboratory testing. For meaningful laboratory results, specimen from a minimum of four and preferably more, up to a maximum of 10 ill persons should be obtained during the acute phase of illness. For public health purposes, an outbreak of norovirus-caused acute gastroenteritis is considered confirmed if stool or vomitus specimens from two or more ill persons are positive for norovirus by RT-PCR, EIA, or electron microscopy.

Infection and Transmission Control Hand hygiene is the single most important method to prevent norovirus infection and to control transmission. Washing the hands for one minute with soap and running water, rinsing for 20 seconds, and drying with a disposable towel is the recommended protocol. Hand sanitizers should not be considered as a substitute for soap and water for healthcare workers and/or for food handlers, or individuals such as family members who are in direct contact with patients. Recognizing the highly infectious nature of norovirus, exclusion and isolation of infected persons are often the most practical means of interrupting transmission of virus and limiting contamination of the “broader” local environment. This is particularly important in care settings where people reside or congregate in close quarters, such as long-term care facilities and acute-care hospitals. Certainly the same concept applies to cruise ships and college dormitories, of course, should an outbreak be identified in such “close quarter” living spaces. Disinfect contaminated surfaces by wiping surfaces with detergent to remove particle debris followed by hypochlorite bleach (5,000 ppm) as the disinfectant. It should be noted that common concentration of household bleach solution [¼ cup (2

oz.) household bleach per gallon of water] makes an acceptable cleaning solution. Other disinfectants are less efficient (quanternary ammonium compounds, alcohols), and alcohol-based disinfectants have been confirmed to be insufficient.

Summary Norovirus is a highly infectious, transmissible agent. It is responsible for approximately 50 percent of acute gastroenteritis and is a major cause of foodborne illness. As little as 18 virions are all that is needed for infection. Viral shedding precedes clinical illness in greater than 30 percent of patients. Prolonged shedding occurs up to eight weeks in healthy individuals and up to one year in immunocompromised hosts. There are asymptomatic shedders. The virus can withstand a wide range of temperatures and persists in the environment. Immunity is short-lived and not cross-protective against antigenic variants. Periodic emergence of epidemic strains occur particularly in norovirus Genogroup II type 4. Molecular diagnostic techniques have improved, enhancing detection ability and accuracy. There is no national requirement to report individual cases of norovirus by the treating physician. The state does require norovirus outbreaks among higher numbers in identifiable populations, e.g., in acute- and long-term care, be reported. Practical transmission control measures should focus on hand hygiene, local environmental disinfection, and management of access to and movement of acutely infected individuals. Dr. Peters, SDCMS-CMA member since 2000, is a board-certified family physician in private practice and a member of Sharp Community Medical Group. He is treasurer of SDCMS, sits on SDCMS’ GERM Commission, co-chairs Sharp HealthCare’s Primary Care Conference, is chair of CMA’s Council on Ethical Affairs, and sits on the San Diego Academy of Family Practice board of directors. Dr. Peters earned a PhD in biochemistry from the University of California in 1975. He serves as a consultant to biomedical companies and is involved in vaccine clinical trials as a principal investigator. Dr. Peters is a recipient of this year’s Physicians of Excellence Award 2011, Top Doctors.

An Innovative Collection and Accounts Receivable Management Company

• Bad Debt Collections • Self-Pay & Insurance Clean-Up • Backlogged A/R Liquidation • System Conversion Clean-Up • Online Account Placement • Access Your Accounts Online 24/7 • More Time to Focus on Patient Care To find out more about our services and how we can help you start collecting more money, contact us today.

www.tscarsolutions.com

To learn more about our services, contact our sales department at 760-681-5019 or sales@tscarsolutions.com

Trust A Common Sense approach to IT Trust us to be your Business Advisor Hardware + Software + Networks Security + Support + Maintenance

Endorsed by SDCMS Member of the California Association of Collectors and ACA International

Ofer Shimrat (858) 569-0300 www.soundoffcomputing.com

ISO 9001:2008 Certified

Take credentialing off your to-do list Introducing CredentialSafe, the next-generation Practitioner Credentialing Management Platform. CredentialSafe eliminates repetitive data entry and time spent on credentialing tasks. • • • • •

Free Free Free Free Free

Easy Print CPPA Application Document Storage for all Certications Credentialing Information Management Alert System to manage expiring credentials Web-based Secure Platform - No software to buy

Ente

Win

For a limited time, A-Check is offering San Diego Physician Magazine readers a free CredentialSafe charter membership and a chance to win a free iPad 2. Visit our website for details.

r to

a Free iPad 2!

Visit:

www.CredentialSafe.com

Division, A-Check America, Inc. - 1501 Research Park Dr. - Riverside, CA 92507 - Toll free: 877-345-2021 ext. 3219

003_SDP

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 25

Infectious Disease

Immunizations

Doctors Need to Do More Than Just Give Shots! By Mark H. Sawyer, MD, FAAP

Most agree that immunizations are important. It is worth noting that David Satcher, the surgeon general at the end of the 20th century, declared that immunizations were one of the top public health advances of the entire century. Dr. Satcher made this statement not only based on the immense impact vaccines have had on the public’s health but also based on how cost-effective vaccines are. I need not remind you of the strains on healthcare resources that we face as we settle into the second decade of the 21st century. To preserve the successes we have gained through immunization, doctors need to do more than just give shots. They need to educate about vaccines; they need to evaluate their own performance giving vaccines; and they need to advocate for vaccines.

Why Do We Need Education? Many of our patients remain confused by the unfounded myths about vaccines that

26 SAN DIEGO PHYSICIAN.org Oc tober 2011

circulate widely in our community. Myths like “vaccines cause autism,” “vaccines overwhelm the immune system,” “the flu vaccine makes me sick.” Our patients are bombarded in the media and on the Internet with inaccurate and misleading information. Although numerous studies show that patients trust their doctor more than anyone for health information, if we don’t spend time educating our patients, they will turn to other sources for information, and quickly find themselves in the quicksand of misinformation in our community.

Why Do We Need to Evaluate Our Performance? Because we are doing a mediocre job of immunizing our community. In San Diego County, only 69–77 percent of adults 65 and over get an influenza vaccine every year. Only 45 percent of our younger adults (18–49 years of age) with health con-

ditions do. Only 47 percent of adolescents in San Diego have received meningococcal vaccine, and many fewer (27 percent of adolescent females) are getting HPV vaccine. We still have babies who are unimmunized, some because their parents have been given bad information about vaccine risks and benefits, but others because medical providers are missing opportunities to vaccinate. No doubt we are awash in requests and activities to evaluate our performance. I’m not suggesting you add more. Just ask yourself two questions: “Do I think about immunizations every time I see a patient?” and “Are my staff and I fully immunized?” The first question is all you need to improve your delivery of immunizations. Every patient is potentially in need of a vaccine, and every patient encounter is an opportunity to give one. If you miss that opportunity, it may be lost forever. You can give vaccines during acute care illness visits, in the emergency department, and in the hospital.

The second question — “Are my staff and I fully immunized?” — is more important. This question speaks to whether you believe in the importance of immunizations. In San Diego only 60–70 percent of healthcare workers get an annual influenza vaccine, and many fewer have received a Tdap. In this era of uncertainty in the community about vaccines, it is more important than ever to lead by example. Just like doctors who smoke, doctors who don’t get immunized themselves send a powerful message to their patients.

Why Do We Need to Advocate for Vaccines? Look no further than your reimbursement levels for vaccine purchase and vaccine administration. California still lags behind many other states in levels of vaccine reimbursement, and San Diego lags behind other California communities. We need to advocate for adequate reimbursement. We also need to advocate for better processes to assure adequate immunization. For years California has been trying to build

a statewide database or registry of patient immunization records to allow the easy transfer of this crucial information between providers. We are still waiting. For years we have talked about reviewing the mechanism by which parents can opt out of immunizations for their children at the time of school entry. We are still waiting, and in the meantime seeing outbreaks of measles and pertussis in our schools. Physicians in San Diego have two valuable but largely unheralded partners in the effort to promote immunizations: our local and statewide immunization coalitions. The San Diego Immunization Coalition (SDIC) just celebrated its 20th anniversary and is active in all areas of immunization in our community. The California Immunization Coalition (CIC) is a private, nonprofit organization whose mission — to achieve and maintain full immunization protection for all Californians to promote health and prevent serious illness — aligns with the goals of physicians. Both SDIC and CIC provide leadership in implementing immunization education

Just like doctors who smoke, doctors who don’t get immunized themselves send a powerful message to their patients.

stability matters. If there is one thing to learn from the recent financial turmoil, knowing who to trust is paramount. Medical Protective, a proud member of Warren Buffett’s Berkshire Hathaway, has always believed that to provide our healthcare providers the best defense in the nation, our financial stability needs to be rocksolid, stronger than any other company. Stability even in the worst of times. Medical Protective is the only medical professional liability insurance company to protect their healthcare providers through all the business and economic cycles of the last 110 years, including the tough economic times of the Great Depression. We are also proud to have provided unmatched defense and stability during all the medmal crises.

We have received higher ratings from A.M. Best and S&P than any other carrier in the healthcare liability industry.

Trust Stability. Trust Medical Protective. Contact Kevin Spitz today for a medmal insurance check-up and a FREE, no-obligation quote. Call: 800-4MEDPRO ext. 3740 Email: experts@medpro.com Visit: www.medpro.com Contact your local Medical Protective agent All products are underwritten by either The Medical Protective Company® or National Fire and Marine Insurance Company,® both Berkshire Hathaway businesses. Product availability varies based upon business and regulatory approval and may be offered on an admitted or non-admitted basis. ©2011 The Medical Protective Company.® All Rights Reserved.

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 27

Infectious Disease

and advocacy campaigns in California and serve to connect physicians, immunization advocates, health departments, and the public. Activities include community outreach, educational materials development, professional and policymaker education, and technical assistance and guidance to local and regional immunization activities.

What Has SDIC and CIC Done for Physicians? SDIC sponsors local community campaigns such as the annual Kick the Flu Summit, which educates healthcare providers from all backgrounds and raises flu awareness with patients. SDIC also communicates to local state legislators to promote immunization issues. CIC is a major force in Sacramento. CIC was instrumental in the development and passage of AB 354 — the Tdap immunization requirement for 7th–12th grade that went into effect July 1,

2011. CIC successfully developed legislation that was instrumental in the creation of the California Immunization Registry. Whenever there is important legislation related to immunizations proposed in California, CIC is there to make sure the right thing gets done. CIC often joins forces with the California Medical Association in legislative advocacy. Key SDIC and CIC areas of focus that are important to physicians include: • Support for adequate reimbursement of physicians in providing vaccinations to children and adults • Education of the community on new immunization issues • Adequate funding for the California Department of Public Health Immunization Branch • Support for funding for continued development of the statewide immunization registry (CAIR) • Education campaigns that highlight a

growing concern regarding the use of personal belief exemptions from vaccination that is putting our communities at risk for resurgence of preventable diseases

What Can Physicians Do for Immunizations? Get Involved Educate, evaluate, and advocate. Ask yourself the two big questions about immunizations. Check out SDIC (www.sdizcoalition.org) and CIC (www.immunizeca.org) and consider joining. Do more than just give shots. Help our children, adolescents, and adults live healthier and free from vaccine-preventable diseases. Dr. Sawyer, SDCMS-CMA member since 2010, is professor of clinical pediatrics at the UC San Diego School of Medicine and Rady Children’s Hospital San Diego and sits on SDCMS’ GERM (Group to Eradicate Resistant Microorganisms) Commission.

Healthcare Banking You Can Count On Our team of Healthcare Banking Specialists can assist you with: � Commercial real estate loans � Equipment loans and leases � Professional checking accounts and merchant card services Discover the service and convenience of: � Assigned Relationship Managers � On-site account opening and servicing � Quick, local decision making

Patrick O. Schulze

patrick.schulze@firstcitizens.com 858-332-3921

28 SAN DIEGO PHYSICIAN.org Oc tober 2011

Support the advertisers who support your magazine!

A-Check America, Inc. AKT, LLP AKW Medical Amador Physician Services Colliers Cooperative of American Physicians First Citizens Bank First Republic Bank Imaging Healthcare Specialists Kaiser Permanente Kolah Law, PC Medical Protective Norcal Mutual Insurance Nova Communications Polaris San Diego Arthritis Medical Clinic San Diego Radiosurgery Sexuality Clinic Soundoff Computing TSC Accounts Receivable The Doctors Company

When calling an advertiser, mention you saw their advertisement in San Diego Physician magazine.

Oc tob er 2011 SANâ&#x20AC;&#x2C6;DIEGOâ&#x20AC;&#x2C6;PHYSICIAN.org 29

Infectious Disease

Healthcare-associated

Infections

Year Three (2011) Legislative Update By Kim Delahanty, BSN, PHN, MBA, CIC

30 SAN DIEGO PHYSICIAN.org Oc tober 2011

A key focus for hospitals is the prevention of healthcare-associated infections (HAIs). In 2008, SB 1058 (Alquist) was enacted, requiring all acute-care hospitals to report certain HAIs, including some surgical-site infections. Since that time, no further clarification of the National Healthcare Safety Network (NHSN) surgical-site infections (SSI) reporting component of the law has been issued to provide hospitals with the guidance necessary to appropriately report these SSI infections. On April 27, 2011, the California Department of Public Health (CDPH) issued an All Facilities Letter (see www. cdph.ca.gov/programs/hai/Documents/ LNC-AFL-11-32.pdf for a complete list of surgeries required to publically report), mandating that hospitals begin reporting 29 surgical-site infections beginning June 1, 2011. Traditionally, infection prevention programs in hospitals have performed annual risk assessments, looking to see how best to protect patients, healthcare workers, visitors, and others in the healthcare environment. They have focused their activity on the high-risk and/or high-volume procedures, with the intent of best serving their clients. Surgeon documentation of key elements of the surgery — such as the wound class, ASA score, and cut/close time — is paramount for accurate risk stratification. SSI surveillance is complex and must be done by someone with expertise in infection prevention and NHSN SSI surveillance concepts, criteria, and definitions. This is a lengthy process, roughly 60 minutes for one chart review and then data entry. In addition, in order to effect change, this data must be analyzed, distributed, and process improvements implemented to the end-users and leadership. Infection preventionists (IP) and hospital epidemiologists must undergo training, with the very short implementation time outlined by CPDH. With these very specific reporting requirements there is simply not enough trained personnel available in California.

We We stand stand for total health. Infection prevention programs are not just “counting numbers.” They have responsibilities, including feeding the data and findings back to the frontline providers; making recommendations for process improvements based on science and evidence to improve patient safety; overseeing employee health and safety; providing education of healthcare workers and patients; construction oversight; and managing leadership and administrative issues for the organization.

In 2008, SB 1058 (Alquist) was enacted, requiring all acute-care hospitals to report certain HAIs, including some surgical-site infections. CDPH has issued four publically reported HAI reports this year (see www. cdph.ca.gov/programs/hai/Pages/default. aspx). CDPH should be commended on their attempt to analyze, interpret, and risk stratify this complex data for consumer perusal. Please keep in mind that this 2011 update does not include all other state and federal mandatory regulatory HAI requirements, such as CMS and The Joint Commission reporting of catheter-associated urinary tract infections and other HAIs. In order to meet the requirements of ALF 11–32, it is feared that diverting IPs from the frontline to data review and entry will have unintended consequences of diminishing the effectiveness of the infection prevention programs in hospitals, which directly impacts patient and employee safety. This law could have the direct opposite effect it was intended for and create patient harm. Ms. Delahanty is administrative director, Infection Prevention Clinical Epidemiology/TB Control, at UC San Diego Health Systems.

for total health.

At Kaiser Permanente Southern California, we believe our achievements are best measured by the health and wellness of the community we serve. That’s why we provide a fully integrated system of care guided by five key elements – prevention, excellent care, top doctors, compassion and innovation. If you would like to work with an organization that gives you the tools, resources and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente. We currently have the following opportunities in the San Diego area: Full-time Openings • Addiction Medicine • Anesthesiology • Cardiology • Child and Adolescent Psychiatry • Emergency Medicine • General Internal Medicine • General Surgery • Hospitalist Medicine

• Infectious Disease • Occupational Medicine • Orthopedic Surgery - Total Joint • Pediatrics • Physical Medicine & Rehabilitation • Psychiatry • Pulmonary/Critical Care • Urgent Care

Per Diem Openings • Physical Medicine & Rehabilitation

• Urgent Care

The advantages of working with us 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 and benefits package that’s designed to impress you. San Diego’s amazing climate, recreational opportunities and cultural attractions continually earn us top ratings as one of the country’s best places to live, work and play. We feature miles of shoreline, year-round sunshine, breathtaking surroundings and a stunning array of outdoor activities. For consideration, please call (800) 541-7946 or apply at http://physiciancareers.kp.org/scal. We are an AAP/EEO employer.

Southern California Permanente Medical Group

Give Us 5 Minutes and We’ll Give You a Benefits Check-up!

Call SDCMS at (858) 565-8888 to schedule a time Today!

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 31

Looking for a way to give back to the community? The San Diego County Medical Society Foundation’s (SDCMSF) mission is to address the unmet San Diego healthcare needs of all patients and physicians through innovation, education, and service. SDCMSF is proud to partner with volunteer specialty physicians and nearly 100 community clinics in the county who provide primary care services for the medically uninsured and underserved. These clinics have little to no access to specialty care for their patients and need your help!

Opportunities for Physicians 1

Volunteer for Project Access San Diego:

If you are a specialist in private practice in San Diego, please consider joining more than 180 specialists in the county by seeing a limited number of uninsured adult community clinic patients in your office for free. Project Access coordinates all aspects of care so your volunteerism is hassle-free for you and your office staff.

Volunteer for eConsultSD:

eConsultSD allows primary care physicians from the community clinics in San Diego to articulate a clinical question to a specialist and receive a timely response in a HIPAA-compliant, web-based portal. eConsultSD is an easy way for busy specialist physicians to give back to the community who are not able to provide direct patient care.

Obtain a Volunteer or Paid Position at a Local Community Clinic: SDCMSF is happy to connect specialist physicians with a community clinic that needs your services on site. This opportunity involves traveling to a clinic within San Diego County as your schedule permits.

Make a Contribution:

SDCMSF needs your support to care for the medically underserved in our community. Please consider making a contribution of any size to support the Foundation’s efforts. Contributions can be made online at SDCMSF.org or sent to the San Diego County Medical Society Foundation at 5575 Ruffin Road, Suite 250, San Diego, CA 92123. Thank you for your support!

Thank you for your dedication to the medically underserved. If you are interested in any of the opportunities above, please contact Lauren Radano, program manager, at (858) 565-7930 or at Lauren.Radano@SDCMS.org. The San Diego County Medical Society Foundation is a 501(c)3 organization (Tax ID # 95-2568714). Please visit SDCMSF.org for more information. Telephone: (858) 300-2777 or Fax: (858) 569-1334

SDCMSF was formed as a separate 501(c)3 in 2004 by the San Diego County Medical Society.

32 S AN D I E G O P HY S I CI A N. or A u gu2011 st 2011 32 SAN DIEGO PHYSICIAN.org Ocgtober

Professional Services Nova Communications

Time is money. Let us assist you and make the most of your time with effective communication that can mean more profits, reduced overhead, added flexibility and less aggravation.We provide: ✓✓ Live Answering Service ✓✓ Alphanumeric/text paging ✓✓ Voice Mail ✓✓ 24 hours/7 days a week service We are a whole lot more than a plain old answering service. Contact Nova Communications to maximize your time and efficiency.

858.565.7970 | www.novacomnet.com

Amador Physician Services Medicare revalidation is coming. Are you ready? Amador Physician Services can handle this task for you and your practice. Let us take care of the paperwork so you can take care of your patients.

925.249.9510 | info@amadorphysicianservices.com

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

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.

858.483.1430 | www.sextherapyofsandiego.com

Kolah Law Kolah Law is a San Diego based law firm that practices in the following areas of law: Healthcare, Business, Corporate, Estate Planning & Asset Protection, Lobbying and Alternate Dispute Resolution. Kolah Law is a unique law firm because it provides personalized niche legal services in many areas of Healthcare law. Further, Kolah Law is devoted to listening and communicating with clients to understand their short and long-term goals, and helping to make their practices successful with proven results.

858.546.4480 | www.lawfirmofsandiego.com

Looking for a cost-effective 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

Your Contact Info Here Oc tob er 2011 SAN DIEGO PHYSICIAN.org 33

classifieds CLINICAL TRIALS CLINICAL RESEARCH STUDY FOR OPERABLE BASAL CELL CARCINOMA (BCC): Do you have patients whom you would consider for participation in a clinical research study for operable basal cell carcinoma (BCC)? If so, please refer them to Skin Surgery Medical Group’s Research Department. The research team at the facility is conducting a clinical study involving an investigational drug that is designed to inhibit a key pathway in cells, known as the Hedgehog pathway, which may be involved in the development of basal cell carcinoma. In this clinical study, the investigational drug is an oral tablet. Enrolled participants will receive study-related medical evaluations and the investigational drug at no cost. They will be compensated for study participation. Patients are eligible if they are 21 years or older, have previously untreated operable basal cell carcinoma, meet other study specific criteria. For more information, call the Research Department at (858) 292-8641. [962] PHYSICIAN POSITIONS AVAILABLE 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]

Experienced Physician Assistants Full-time & Per Diem

Openings: Murrieta, Pomona, Orange, Moreno Valley, Valencia, Chatsworth, Del Amo, Saugus, Oxnard, National City, Stockton , Livingston, Turlock & Modesto One year experience is required. Occupational Medicine and Urgent Care practice experience is preferred. Apply! No new grads please providerrecruitment@ushworks.com www.ushealthworks.com EOE SEEKING GENERAL MEDICINE AND ORTHOPEDICS PHYSICIANS: The VA San Diego Healthcare System is actively seeking general medicine (GM) and orthopedics physicians to perform veterans’ disability examinations at VASDHS Compensation and Pension Clinics located in San Diego and/or Oceanside. The GM physician is required to have an internal medicine, occupational medicine, or family practice background. For the orthopedics physician, general orthopedics or occupational medicine training is preferred. Reimbursement for the disability examinations can be either on a fee-per-case basis for 1–2 days per week or on a part- or full-time salary. Computer skills are required. No clinical or continuity of care work is required. Must be a U.S. citizen. VASDHS is an EEO employer. Email your CV to Dr. Hong Huynh at hong. huynh@va.gov. [981] SUPERVISOR INFECTION CONTROL — SHARP HEALTHCARE: Sharp HealthCare is seeking a full-time RN, MD, or science-related professional with two years of clinical infection control experience. CIC (Infection Control Certification) is required. Led by nationally recognized experts, the Sharp Metropolitan Metro Campus (SMMC) infection prevention and clinical epidemiology department is comprised of six skilled infection preventionists who work closely with the medical director / hospital epidemiologist. We are seeking candidates with a passion for infection prevention and a collaborative,

solution-oriented approach to practice. For additional information regarding the position and job requirements, please visit our website at www.sharp.com/jobs and keyword search for “Supervisor Infection Control.” Apply online at www.sharp.com/jobs and click “Search Jobs.” For more information, contact Lori Gunter RN, BSN, with Sharp HealthCare recruitment, at lorena.gunter@sharp. com. Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer (M/F/D/V). [976] INTERNAL MEDICINE OPPORTUNITY: Full-time, BC/ BE internist to join private practice in Escondido. Inpatient/outpatient care with hospitalist rotation. Competitive salary, malpractice, benefits, and partnership potential. CV to EIM2011SDP@gmail.com. [970] PHYSICIAN AND FAMILY NURSE PRACTITIONER FOR AMBULATORY CLINIC: Southern Indian Health Council is made up of board-certified physicians who are experts in primary care and health management. Working closely with a well-trained support staff, our medical providers have established a solid reputation of delivering quality outpatient care and a broad scope of services to individuals of all ages. We are seeking a fulltime, board-certified physician and/or nurse practitioner Monday–Friday, 8:00am–4:30pm. Must have current CA and DEA licenses; computer skills. A competitive salary, health benefits, vacation, paid holidays, sick time, CME, licensing reimbursement, malpractice coverage offered. Forward resume to jobs@sihc.org or fax to (619) 4457976 or visit our website at www.sihc.org. Contact jobs@ sihc.org or HR phone (619) 445-1188, ext. 291, or HR fax (619) 445-7976. [969] BC FAMILY PRACTIONER MD/DO WANTED TO JOIN OUR PRACTICE IN BEAUTIFUL CORONADO: Seeking FT family physician to join our practice before July 2012. There would be a salary assistance guarantee through a leading local IPA for first year and also a buy-in opportunity as well. The ideal candidate would be willing to share practice with one FT FP and PT FP in practice together and share call and expenses. There would be additional earning opportunities for PT inpatient hospitalist at local hospital as well. Hospital work is optional however. We provide a full range of pediatric and adult family medicine (but no OB). Our practice is well known and has a reputation of personal excellence and service to a wonderful community in an ideal location. Also there is very good earning potential as well. If seriously interested in this unique opportunity, please send your CV and references to donalddill@sbcglobal.net, Attn: Gloria Rivera, or call (619) 435-3155 or fax (619) 435-3158. [968] BC/BE FAMILY PRACTICE PHYSICIANS: North County Health Services is a Joint Commission accredited, FQHC, celebrating nearly 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 family practice physicians for both full-time and per-diem positions. Spanish communication skills are helpful but not required. Compensation includes attractive base, incentive, and great benefit programs, malpractice, reimbursement for CME and 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. Contact cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [966] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, 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. Visit our website at www. vistacommunityclinic.org. EOE/MF/D/V [912] CHIEF MEDICAL OFFICER: Mountain Health and Community Services (MHCS) is an established, four-site, Federally Qualified Health Center serving both rural and urban medically underserved residents of San Diego

County. A competitive salary, medical benefits, vacation, paid holidays, sick time, CME and licensing reimbursement are offered. Board-certified family practice and English/Spanish preferred. Position is 60% clinical and 40% administrative. Please send CV and salary requirements to tfindahl@mtnhealth.org or contact Tabitha at (619) 478-5254, ext. 30. Visit www.mtnhealth.org. [960] Internal Medicine: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine physician to join our staff. We offer a first-year competitive compensation guarantee and excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax (619) 2334730. Email lori.miller@sharp.com. [951] Dermatology: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking a full-time BC/BE dermatologist to join our staff. We offer a first-year competitive compensation guarantee and excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax (619) 233-4730. Email lori.miller@ sharp.com. [950] FAMILY MEDICINE: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time BC/BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [928] 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 full-time). [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] PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE IN NATIONAL CITY: $318,000 yearly average gross earnings for the past three years. Office-based busy practice of 31 years on the busiest street of the city. Option to add hospital practice to the office practice, with the nearest hospital 1.6 miles close. Two other nearby hospitals are less than 7 miles. Easily accessible location right between two freeways, I-5 and I-805. $89,000–$99,000. Terms negotiable. Financing if needed. Call (619) 948-4946 anytime or (619) 449-4318 7pm–2am. [945] INTERNAL MEDICINE PRACTICE FOR SALE: Beautiful beach weather, established 27 years with excellent reputation. Two exam rooms. Free-standing building. Main street corner location. Great visibility. Office shared with another physician. Patient parking. 2010 gross: $483K. Asking $245K. 100% financing available. Please contact ProMed at (888) 277-6633 or at info@promed-financial. com, or visit www.promed-financial.com. [906]

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. 34 SAN DIEGO PHYSICIAN.org Oc tober 2011

OFFICE SPACE / REAL ESTATE PLEASE CONTACT IF YOU HAVE OFFICE SPACE AVAILABLE TO SUBLET: Will consider any area in greater San Diego but would specifically be interested in Poway, Escondido, Vista, North County, as well as East County/La Mesa. Prefer situation where we can use existing office staff. Contact sundhmail@yahoo.com. [983] SCRIPPS ENCINITAS CONSULTATION ROOM/EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] MEDICAL OFFICE SPACE FOR LEASE, 1,215 SQ FT: Office has furnished waiting area, front and back stations for four staff members, two exam rooms, a break room, and doctor’s office. Office is updated and is ready for move-in. Located in a great medical/dental complex in Poway, close to Pomerado Hospital, on the border with Rancho Bernardo. Second floor. Elevator/stair access. Large, free patient parking area. Ideal for medical, complementary/alternative medicine, physical therapy, chiropractic, acupuncture, massage/body work, etc. Patients from Poway, Rancho Bernardo, Carmel Mountain, 4-S Ranch, Scripps Ranch, Escondido, Ramona, and surrounding areas. Affordable rent. Please contact Olga at (858) 485-8022. [980] CONSULTATION ROOM AVAILABLE: On the campus of Scripps Encinitas, close to 5 freeway. Private entry to wheelchair-accessible unit with soundproof walls, spacious waiting room shared with one doctor, BR with shower, reserved parking. Flexible sub-lease terms. To view the property (available now), please contact (760) 944-9263. [979] OFFICE SPACE TO SUBLEASE: At 754 Medical Center Court, Suite 101, Chula Vista, CA 91911. Close to Sharp Chula Vista Hospital. Includes one office and three exam rooms. If interested, please call (619) 994-4366. [978] SCRIPPS / XIMED BUILDING, LA JOLLA OFFICE SPACE TO SUBLEASE: Currently occupied by one fulltime and three part-time physicians. One office available plus one exam room. Receptionist space available for your employee. For more information, contact Mary at (858) 457-3270. [975] OFFICE FOR LEASE: Beautiful turnkey 1,800-squarefoot medical office space for sublease in Encinitas on El Camino Real with lighted signage and wall signage on El Camino Real. Ideal drive-by advertising. $80,000 worth of tenant improvements with in the last two years. Hardwood flooring, designer decorated and coordinated walls, cabinets, and counters. Five exam rooms and beautiful nursing and reception areas all perfectly appointed. Waiting room with leather couch matching designer furniture and credenza. Phone system, T-1 line, surround-sound muzac system, E-clinical version 9 EMR, new server, all offices fully furnished with new exam tables, computers, and Welch Allen oto/optho sets. 4,700 active primary care patients with healthy cash-based practice. Rent is currently $4,900 a month. Office hard assets and goodwill are negotiable. Physician could lease the space, buy the practice, or work as a guaranteed employee. Please contact Judith Rubin, MD, at judyr@nouveauhealth.net. [973] PATIENT INTERVIEW OFFICE: Patient interview office available on the campus of Scripps Encinitas Hospital, adjacent to Highway 5 Santa Fe exit. First floor, four office private suite, with two established psychiatrists, and one psychotherapist. Full- or part-time lease available. Use of front office staff negotiable. [971] HILLCREST OFFICE SPACE AVAILABLE: Office space available at the corner of 8th Avenue and Washington St. in Hillcrest. Approximately 3,000 sq. ft. Surgical center building. Ample parking and freeway access. Proximity to Scripps Mercy Hospital. Contact Laura Hurshman at (619) 299-5000 or at laura@sdhandcenter.com. [874] MEDICAL OFFICE SPACES FOR RENT/PRE-LEASE, NEW CONSTRUCTION, VERY AFFORDABLE: 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 from 950 to 1,500 sq. ft. available. Now leasing. Call Nathan at (619) 787-3422 or email hythams@att. net. [967]

SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867]

3998 VISTA WAY, IN OCEANSIDE: Two medical office spaces approximately 2,000 sq. ft. available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price: $1.95 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@ coveycommercial.com. [965]

OFFICE SPACE IN UTC: Full- and part-time office in 8th floor suite with established psychologists, marriage and family therapist, and psychiatrist in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Contact Christine Saroian, MD, at (619) 682-6912. [862]

PRESTIGIOUS OFFICE SPACE IN THE SCRIPPS LA JOLLA XIMED BUILDING TO SHARE/SUBLET: This suite is currently a (+/-) 4,486 sq. ft. expansion to a dermatology office, offered at competitive lease terms. It offers several rooms that may be used as offices, examination or consultation rooms. Includes fully furnished, renovated reception/lobby area, janitorial services, access to common areas, sweeping views, onsite parking. Lessee is to verify all information prior to signing a lease. Located in the Ximed bldg. in Scripps Memorial Hospital in La Jolla. Interested parties call Kelley at (858) 362-8800. [964] SUBLET 1 OR 2 EXAM ROOMS AND PHYSICIAN OFFICE: Beautiful, new, spacious medical office suite located at 801 Orange Avenue, Coronado, CA 92118. Shared waiting room, break room, and reception area. Majority of suite is presently occupied by a specialty physician. Ample, free, covered parking provided. Close proximity for patient convenience. For more information, please contact Karen at (619) 437-4406. [963] SHARE OFFICE SPACE IN LA MESA: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. 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] SCRIPPS/XIMED BUILDING, LA JOLLA, OFFICE SPACE TO SUBLEASE: Occupied by vascular and general surgeons. One room office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, Ximed Building is the office space location of choice for anyone doing surgeries at the hospital or for anyone seeking a presence in the La Jolla area. Reception and staff available if needed. Full ultrasound lab on site in office for anyone interested in this service. For more information, call Irene at (619) 8402400 or at (858) 452-0306. [921] NORTH COAST HEALTH CENTER, ENCINITAS, OFFICE SPACE TO SUBLEASE: Newly remodeled and beautiful office space available at the 477 Building. Occupied by seasoned vascular and general surgeons. One office and two exam room available. Great window views and location with all new equipment and furniture. Full ultrasound lab and tech on site for extra convenience. New hardwood floors and exam tables. Staff available for an add-in if needed. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858)-452-0306. [922] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL 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, OB/GYN, 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 medical, 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) 504-5830. [835]

OFFICE SPACE TO SHARE: Currently occupied by orthopedic 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] NONPHYSICIAN POSITIONS AVAILABLE PA/NP POSITION: PA/NP needed in busy neurosurgery private practice. Candidate needs to be highly interested and motivated, as well as caring and flexible. Will be asked to conduct patient clinics, hospital rounds, and assist in surgeries. If interested, please send email with CV and references to armonia01@me.com. [977] SUPERVISOR INFECTION CONTROL — SHARP HEALTHCARE: (see ad #976 under “Physician Positions Available”) PHYSICIAN AND FAMILY NURSE PRACTITIONER FOR AMBULATORY CLINIC: (see ad #969 under “Physician Positions Available”) MEDICAL EQUIPMENT ELECTRONIC TOUCH SCREEN MEDICAL CHECK IN SYSTEM FOR SALE: Eliminate staff interruptions and increase your office efficiency with this easy-touse patient sign-in kiosk in your waiting room. The average sign-in time for patients with a Medical Check In touch-screen kiosk takes fewer than 10 seconds. With this reduction in interruptions and the clear, organized communication of patient information to your receptionist’s computer, Medical Check In will reduce the time for the patient sign in process, reduce congestion for your reception area and save you money. Compatible with all electronic health records. Still under warranty. Cost for new Medical Check In is $2,500. Great price for this at $995. For more information please see medicalcheckin. com. Email KLewis@SDCMS.org. [982]

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

Oc tob er 2011 SAN DIEGO PHYSICIAN.org 35

SDCMS Foundation

Left: Patient Irene Espinoza is very happy that people like Dr. Adam Fierer “have a good heart.” This surgery will help her be active again, and she hopes to lose the weight she gained during the years she lived with the pain form her large inguinal hernia. Above: Dr. Adam Fierer (left), patient Cecilia Pimentel, and Rick Vilela (pre-op LVN, right). Ms. Pimentel lived with her umbilical hernia for 10 years prior to having it corrected on Aug. 27, 2011.

The First North County Project Access Surgery Saturday by Rosemarie Marshall Johnson, MD Inspired by the successful partnership over the past three years between Project Access San Diego and Kaiser Permanente that provided seven surgery days, $2 million in donated services, and more than 240 procedures to grateful uninsured adults in our community, Project Access teamed up with the professional staff at Carlsbad Surgery Center, the first outpatient facility in Carlsbad and a member of the Surgery One group. This was our first non-Kaiser Permanente event and was made possible by the generous participation of Adam Fierer, MD, general surgeon, and Mark Ransom, MD, anesthesiologist from Anesthesia Service Medical Group. Thanks to their leadership, five outpatient surgeries were smoothly completed: a laparoscopic cholecystectomy, an umbilical, two unilateral, and one bilateral inguinal herniorhaphies. The team they led was outstanding. Scott Leggatt is the executive director of Surgery One in all four locations: Carlsbad Surgery Center, Orthopaedic Surgery Center of La Jolla Facility, Coast Surgery Center Facility, and Otay Lakes Surgery Center. The 30 volunteer professionals in the preop, postop, and operating areas were led by Mandy Moore, RN, and David Douglas, administrator. 36 SAN DIEGO PHYSICIAN.org Oc tober 2011

Two UCSD medical students shepherded the patients and their families through the day and provided translation when needed. Also volunteering to get a taste of healthcare were the teen daughters of Dr. Ransom, Scott Leggett, and Rick Viela, PA. Every one of the Carlsbad volunteers was delighted to be helping such a worthy cause. They obviously love their work and welcomed our PASD staff warmly. BJ Bodwell, RN, missed her annual volunteer trips to Fiji and thanked us for bringing underserved patients to her. The medical students were very grateful for their first surgical experience and the opportunity to really help patients. Best of all were the patients. All five were in a great deal of pain — some unable to work — and all were compromised in many aspects of life. One patient had been suffering with her hernia for 10 years. All mentioned the postop ability to enjoy family, pick up children, and provide for their family because of the ability to work full-time again. The preop fear of the unknown, although allayed by the gentle care of all, especially their guides, the medical students, was replaced post-op by bountiful happiness and gratitude. One patient said that angels do exist: All those who made

this surgery possible. Another said he felt like he had won the lottery to be chosen for this surgery. Additionally, everyone who made these surgeries possible felt truly rewarded, and, as many of our PASD volunteer physicians have told us, this is why they became physicians. In fall 2008 when Kaiser Permanente facilitated the first Super Saturday, which served as the kickoff to Project Access San Diego, KP leadership hoped their support would inspire others and lead to more patients served. Surgery One is working with PASD to implement quarterly Surgery Saturdays involving additional surgeons, adding to the capacity of the semi-annual KP days. The Oct. 15 KP Super Saturday will help 42 people gain improved health — our biggest surgery day ever! Other community hospitals and outpatient surgical centers provide unreimbursed care throughout the year by offering surgical suites and staffing to PASD volunteer physicians. Our partnership with ASMG and other anesthesiology groups as well as many other ancillary healthcare partners makes our work possible. So the first Project Access-Surgery One Surgery Saturday was a resounding success thanks to the many caring professionals involved. It started with Adam Fierer, who advocated for Surgery One’s involvement after a Doctors Without Borders trip to Nicaragua; his colleague, Mark Ransom; the remarkable generosity of everyone at Carlsbad Surgery Center and Surgery One; and our own devoted staff — Barbara Mandel, Tanya Rovira, Elizabeth Terrazas, Rebecca Valenzuela, and Lauren Banfe — as usual working miracles. To all our physician volunteers and other healthcare partners, thank you on behalf of the more than 900 patients whose health you have improved and whose lives you have changed.

We Celebrate Excellence – Theodore M. Mazer, MD CAP member and tireless champion for access to quality health care, for those in need

800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Diego otolaryngologist Theodore Mazer, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT). Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors. CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection. 37

may 2011 SAN DIEGO P HY SICIA N. o rg 37 Oc tob er 2011 SAN DIEGO PHYSICIAN.org

$5.95 | www.SANDIEGOPHYSICIAN.org San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

WeWe hate hate lawsuits. lawsuits. WeWe loathe loathe litigation. litigation. WeWe help help doctors doctors head head offoff claims claims at at thethe pass. pass. WeWe track track new new treatments treatments and and analyze analyze medical medical advances. advances. WeWe areare thethe eyes eyes in in thethe back back of of your your head. head. WeWe make make CME CME easy, easy, free, free, and and online. online. WeWe dodo extra extra homework. homework. WeWe protect protect good good medicine. medicine. WeWe areare your your guardian guardian angels. angels. WeWe areare The The Doctors Doctors Company. Company. Donald Donald J. Palmisano, J. Palmisano, MD, JD, MD, FACS JD, FACS Board Board of Governors, of Governors, The Doctors The Doctors Company Company Past President, Past President, American American Medical Medical Association Association

The The Doctors Doctors Company Company is devoted is devoted to helping to helping doctors doctors avoidavoid potential potential lawsuits. lawsuits. For us, Forthis us, this starts starts withwith patient patient safety. safety. In fact, In fact, we have we have the largest the largest Department Department of Patient of Patient Safety/Risk Safety/Risk Management Management of any of medical any medical malpractice malpractice insurer. insurer. And,And, locallocal physician physician advisory advisory boards boards across across the country. the country. WhyWhy do we dogo wethis go this far? far? Because Because sometimes sometimes the best the best way way to look to look out for outthe for doctor the doctor is toisstart to start withwith the patient. the patient. The The San San Diego Diego County County Medical Medical Society Society has exclusively has exclusively endorsed endorsed our our medical medical professional professional liability liability program program sincesince 2005.2005. To learn To learn moremore about about our program our program for SDCMS for SDCMS members, members, call us call us at (800) at (800) 852-8872, 852-8872, or visit or visit www.thedoctors.com. www.thedoctors.com.

Endorsed Endorsed by by

38 SAN DIEGO PHYSICIAN.org Oc tober 2011