FEBRUARY 2016 | Physician Magazine by Los Angeles County Medical Association

2016 LAWS | VACCINES • ASSISTED SUICIDE • MEDI-CAL • POLST

REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

THE CHANGING FACE OF MEDICAL EDUCATION

FEBRUARY 2016

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FEB R UA RY 2016 | TA B LE OF CONT ENT S

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Volume 147 Issue 2

FEATURE 6 NEW CALIFORNIA LAWS FOR 2016 Vaccines | Assisted Suicide | Medi-Cal | POLST

14 Top 3 Patient Safety Tips: Reducing Technology Risks

COVER STORY

The Changing Face of Medical Education

In this issue, we will examine how, in stark departure from the past, the vast majority of the country’s medical schools are now integrating discussions of cost, value and patient engagement into their curricula. We will also show how today’s residents are making their voices heard via activism and apps to negotiate for better salaries, benefits and other rights with the hospitals that employ them.

FROM YOUR ASSOCIATION 4 President’s Letter | Peter Richman, MD 16 United We Stand | At Work for You

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine,801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Advertising rates and information sent upon request.

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as well as medical students, interns and residents. For more

Christina Correia 213.226.0325 | christinac@lacmanet.org Dari Pebdani 858.231.1231 | dpebdani@gmail.com David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

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Peter Richman, MD Vito Imbasciani, MD William Averill, MD Richard Baker, MD Pedram Salimpour, MD

than 100 years, LACMA has LACMA BOARD OF DIRECTORS

been at the forefront of current medicine, ensuring that its members are represented in the

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ment relations and community

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relations. Through its advocacy

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efforts in both Los Angeles County and with the statewide California Medical Association, your physician leaders and staff strive toward a common goal– that you might spend more time treating your patients and less

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David Aizuss, MD Erik Berg, MD Robert Bitonte, MD Stephanie Booth, MD Jack Chou, MD Troy Elander, MD Hilary Fausett, MD Samuel Fink, MD Hector Flores, MD C. Freeman, MD Sidney Gold, MD Jinha Park, MD Stephanie Hall, MD David Hopp, MD Kambiz Kosari, MD Sion Roy, MD Paul Liu, MD Maria Lymberis, MD Philip Hill, MD Nassim Moradi, MD Vamsi Aribindi Ashish Parekh, MD Jerry Abraham, MD Po-Yin Samuel Huang, MD Michael Sanchez, MD Heather Silverman, MD Annie Wang Nhat Tran, MD Fred Ziel, MD

lenges of managing a practice. LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

SUBSCRIPTIONS Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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P RES IDEN T ’S LET T ER | P ET ER RIC H M AN, M D

“Medical school curriculum has evolved over the past 250 years as the science of medicine, teaching methods and social standards have evolved.”

T H E A M E R I C A N M E D I C A L E D U C AT I O N system began with the School of Medicine at the University of Pennsylvania in 1765. By the late 1800s, there were over a hundred medical schools of varying quality. Following graduation, young physicians would go into general practice, apprentice with an established community physician, live as a house physician at a hospital, or perhaps go to Europe for additional training before returning to establish their practice. Formal residency programs were started by Drs. William Osler and William Halsted at Johns Hopkins Hospital in 1889. The programs were pyramidal in nature with the ultimate chief resident being capable of professorial employment. In 1904, the Council on Medical Education of the AMA recommended that medical school be four years. In 1910, the Flexner Report under the aegis of the Carnegie Foundation led American medical schools to set high admission standards and emphasize the scientific method. Most medical school curricula became four years. Numerous inferior medical schools were closed. In 1904 there were 160 schools; by 1935 that number decreased to 66. Many osteopathic schools closed, and those remaining had teachings similar to allopathic schools. As a negative sexist and racist corollary of this report, women and African-Americans were greatly excluded from the medical education system. Medical school curriculum has evolved over the past 250 years as the science of medicine, teaching methods and social standards have evolved. The Liaison Committee on Medical Education (LCME) of the AMA (1847) and the Association of American Medical Colleges (1876) accredits schools granting a Doctor of Medicine degree. The Commission on Osteopathic Col-

4 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2016

lege Accreditation of the American Osteopathic Association (1897) accredits schools granting a Doctor of Osteopathy degree. These organizations have made national recommendations that have been adopted by the now 141 MD schools and 30 DO schools in the United States. As an aside, women have achieved parity in medical school matriculation, but African-Americans are still underrepresented. Likewise, graduate medical training programs (residency programs) have evolved. These programs are accredited by the Accreditation Council for Graduate Education (1981) composed of the American Board of Medical Specialties, the American Hospital Association, the AMA, the Association of American Medical Colleges and the Council of Medical Specialty Societies. Once a physician obtains a medical license from the Medical Board of California, continuing medical education is required by the state to maintain the license. If a physician is a member of a specialty board, the American Board of Medical Specialties or the medical specialty boards of the American Osteopathic Association, maintenance of certification (MOC) is required. These requirements are different from those required for state licensure. MOC has six core competencies: practice-based learning, patient care and procedural skills, systemsbased practice, medical knowledge, communication skills and professionalism. These are measured within a four-part framework that includes the categories assessment of knowledge, judgment and skills plus lifelong learning and self-assessment. It is easy to see that medical school education, residency and continuing medical education are highly complex processes and have been evolving to meet the needs of twenty-first century patient care. There are many factors influencing this evolution, and there is input from many stakeholders. Sometimes individual physicians feel powerless to have their opinions noted, especially with some cumbersome and time-consuming requirements that are not evidence-based. Once again, organized medicine speaks with a louder voice and, with greater membership, may alter the requirements to meet the needs of both patients and physicians.

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Along with the new rules and regulations covered in our January feature CHANGES 2016, the new year brings with it a host of new state laws that will have implications for physicians. Here’s a roundup of some of the new laws in healthcare that LA County

MEDI-CAL FOR UND O C UM

doctors need to be aware of: SB 277: The widely debated new law removes the personal belief exemption from school immunization and requires that all children be fully vaccinated to attend school – public and private – unless they have a medical exemption. The law starts July 1 in advance of the 2016-2017 school year. A second law related to vaccines requires all school care workers to be vaccinated against measles, pertussis and influenza. SB 277 was placed before state lawmakers following several outbreaks of vaccine-preventable diseases.

VACCINES

Gov. Jerry Brown signed into law the End of Life Option Act, which permits doctors to prescribe lethal medication to terminally ill patients who request it. As of early January, there was no firm date for the law to go into effect, because it was passed as part of an ongoing special legislation session called by the governor to address healthcare financing. In a personal note, Brown said he read opposition materials carefully but in the end was left to reflect on what he would want in the face of his own death, according to news reports. The law is set to expire in 10 years, unless the Legislature passes another law to extend it.

ASSISTED SUICIDE

FOR UNDOCUMENTED CHILDREN California became the first state nationwide to extend state-subsidized health coverage to children who are living in the United States illegally. The law, which will take effect May 1, will make some 170,000 children under 19 eligible for Medi-Cal. Los Angeles County has the highest number of undocumented immigrants in the state (about 815,000), followed by Orange County (nearly 250,000). However, some experts believe that as more people become eligible, the program faces a shortage of doctors since reimbursement payments were cut by 10% during the recession.

MEDI-CAL

Starting Jan. 1, all California-licensed physicians authorized to prescribe, order, administer

CURES and dispense Schedule II, III or IV controlled substances must be registered to access the Controlled Substance Utilization Review & Evaluation System (CURES). AB 679 extends the deadline for enrollment with the Department of Justice to access information in the CURES database to July 1. AB 637 authorizes as valid the completion and signature on the Physician Orders for Life Sus-

POLST taining Treatment (POLST) by a nurse practitioner or a physician assistant acting under the supervision of the physician. The bill stemmed from a SFMS resolution and was a CMA-sponsored legislation.

6 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2016

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THE CHANGING FACE OF MEDICAL EDUCATION The changing healthcare environment in this country is driving our medical schools to also change and go beyond teaching students merely the ins and outs of providing good quality care. In this issue, we will examine how, in stark departure from the past, the vast majority of the countryâ&#x20AC;&#x2122;s medical schools are now integrating discussions of cost, value and patient engagement into their curricula. We will also show how todayâ&#x20AC;&#x2122;s residents are making their voices heard via activism and apps to negotiate for better salaries, benefits and other rights with the hospitals that employ them. 8 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2016

Schools are beginning to help students understand systemic issues that shape individual health and lead the conversation about how to reinvent society’s approach to healthcare and wellness. According to a recent study by the Association of American Medical Colleges, which helps medical schools develop curricula, 129 of 140 responding medical schools offered a required course on the cost of healthcare during the 2013-2014 school year, with 40% of the schools saying they present the issue in elective courses. One of the main reasons for the change is the Affordable Care Act, which is moving toward rewarding doctors for providing high-value care rather than for the number of tests ordered or surgeries performed. In addition, many more people now have high-deductible health plans, which translates into higher up-front out-of-pocket costs for consumers before the insurance kicks in. Consequently, consumers demand more transparency in terms of costs for medical care provided.

The school will redesign physician education around providing high-quality care beyond traditional medical settings, the release said. It will acknowledge the importance of collaboration and teamwork to inform decisions and address disparities in health. Kaiser Chief Executive Bernard Tyson believes Kaiser’s technology-driven, evidence-based model of coordinated care is badly needed. He holds that teaching that approach could bring about faster changes nationwide. “Opening a medical school and influencing physician education is based on our belief that the new models of care mean we must reimagine how physicians are trained,” Tyson said in a prepared statement. “Training a new generation of physicians to deliver on the promise of health and healthcare demonstrates our belief that our model of care is best for the current and future diverse populations in this country.” Kaiser said existing physician education hasn’t evolved to support the multisite, high-tech care-delivery system that has begun to emerge. The school will embrace advanced models of decisionmaking, teamwork, technology, evidence-based medicine and communication strategies tailored to specific populations. Educators will focus on building cultural competency among Kaiser’s students to prepare them for an increasingly diverse patient base, Tyson said. Kaiser intends to extend that emphasis on diversity to its student population as well. The new school is expected to begin the process of recruiting a dean next year.

More people now have high-deductible health plans, which translates into higher up-front out-ofpocket costs for consumers before the insurance kicks in. Consequently, consumers demand more transparency in terms of costs for medical care provided.

SOUTHERN CALIFORNIA MEDICAL SCHOOLS

Kaiser Health News recently reported that in Southern California, medical schools and residency programs are creating new ways to insert cost and value into their curricula. At the University of California, Los Angeles, for instance, discussions of value in healthcare are now part of everyday teaching. Some students may feel overwhelmed with adding yet another aspect of healthcare onto their already busy schedule, but the teachings begin to resonate when they start dealing directly with patients and seeing the impact. Kaiser Permanente announced in December plans to open a Kaiser Permanente School of Medicine in Southern California as part of its effort to lead in meeting America’s demands for 21st century healthcare.

RESIDENTS, BENEFITS & SALARIES

It isn’t just the medical schools themselves that are changing the discussion of finances and value. Increasingly residents, who historically have been unable to negotiate the terms of such things as salary,

T H E C H ANGING FAC E OF M EDIC AL EDU C AT ION | F EAT U R E

REASONS FOR THE CHANGE

Early immersion in patient-centered care, in which doctors consider life circumstances and personal preferences along with symptoms and vital signs, is just one of the trends changing the face of medical education these days, according to a U.S. News & World Reports article. According to the article, some of the most significant emerging trends in U.S medical education include: Face time from the start | Rather than spending the first two years of medical school exclusively in the classroom studying basic medical science, first- and second-year students at some schools are actually conducting interviews with patients in clinics and helping them understand any new drug prescriptions. Second-year students engage in the transition from hospital to home, helping with discharge arrangements and in some cases following up with house calls. Through such programs, trainees see how putting the focus on the patient prevents costly readmissions and leads to better health outcomes. Multidisciplinary teams | Putting that early training into real-world settings also gives doctors-to-be experience working with other health professionals, a taste of the high-powered team medicine they are expected to practice. A social mission | More medical colleges are creating opportunities to help their communities, particularly underserved populations. The strategy: to let students see the health consequences of social and economic inequality, an urgent concern among public health experts. Customizable curricula | No one starts med school with the same knowledge and experience or learns at the same rate, and those variations will only widen as admissions officers look beyond scores and grades. So a growing number of schools are turning to “competency-based” curricula that allow students to progress after mastering certain skills or reaching defined milestones. The idea is to shift from producing doctors who have memorized a lot of information to those who are excellent at what they do and are skilled critical thinkers. Systems of care | The curriculum used to hinge on two things: basic science, or the design and function of the human body, and clinical care, which involves diagnosing and treating bodily ills. Lately schools have focused on a third category of essential intel: system science – how to deliver safe and effective care within a complex system, including everything from reducing errors to understanding costs and how care is financed.

benefits and working hours, are also fighting for more say in these matters. Many have turned to activism and apps to try to negotiate with their employers here in California and elsewhere, according to news reports. The International Business Times, in an article from last September, quoted a first-year resident in emergency medicine who said that “there’s no other profession in the world where somebody will sign a contract that’s non-negotiable, not knowing what city they’re going to be in, not knowing what their salary is going to be and not knowing their benefits.” Indeed, according to the article, hospitals earn millions of dollars from the government for training hundreds of residents a year through an arrangement that critics say is misguided. Meanwhile, the average student pays $6,000 to apply to and interview at top programs, which is a burden to students who are already facing significant debt. In some cases, even after they have landed their dream assignment and begin earning a salary, many residents still find the conditions less than desirable. As a result, residents at some hospitals have formed collective bargaining units to address issues about salary, benefits and working conditions — and do so successfully. Residents in New York City reportedly won a $1,000 bonus; residents at Rutgers University in New Jersey earned a $20 meal credit at the hospital cafeteria when they work overnight or extended shifts and a $50 increase to an annual stipend they can use for buying books or technology. At the University of California, Irvine, residents reportedly fought for the first-ever labor contract and formed the Committee of Interns and Residents (CIR), the largest union in the country for residents, fellows and interns, representing 14,000 members in California, Florida, New York, Massachusetts, New Jersey, New Mexico and Washington, D.C. One of the issues of negotiation was a $5,000-a-year housing stipend. UC Irvine Medical Center requires residents to live within 30 minutes of the hospital so they can quickly respond when being on call. With the average rent in Orange County being $1,807 a month, residents feel that’s burdensome and want the hospital to help ease their pain. DOXIMITY | Formerly flying blind, today’s tech-savvy residents are also turning to apps to get a better idea of the conditions and expectations at various residency programs nationwide. Doximity, a popular app that allows residents in LA County and elsewhere around the country to rate residency programs across 22 specialties, offers more transparency and thus is likely to become a powerful tool for residents to increase their bargaining power. Doximity said it already has some 40,000 residents posting reviews on what life is really like in a particular

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program and rank them based on schedule flexibility and work hours through a five-star system. Before this app, there was no clearinghouse for qualitative and quantitative information on residency programs, the company was quoted as stating. The company said that in 2014 alone, 75% of U.S. medical students used the tool during their search. STRESS | The fight for transparency, salaries and benefits, however, doesn’t go far enough in making other needed changes, according to some physicians and residents. Many believe that the changing healthcare system also demands a more benevolent approach, more personalized training after medical school and also a closer look at gender inequality. According to Kaiser Health News, a large study from several leading medical schools, including Harvard, Yale and England’s Cambridge University, the stress of training can cause depression, which is troublesome, because when residents are depressed they are apt to provide “poorquality patient care” and make more medical errors. Study leader Douglas A. Mata, MD, a resident of pathology at Brigham and Women’s Hospital in Boston, analyzed data from 54 earlier studies involving 17,560 physicians in training. The study, published in the Journal of the American Medical Association (JAMA), found that nearly one-third of interns and residents experience depressive symptoms or full-blown depression at some point during their training, Kaiser Health News reported. That rate is higher than the rate for either medical students or practicing physicians who have finished their training, and substantially higher than the rate of the general public, and, many would argue, is disconcerting given that these professionals are here to heal others. A big part of the problem is that medicine has long been taught by treating “underlings harshly,” which has been considered acceptable because a mistake could cost a patient her life, according to University of 1 2 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2016

Nevada Medical School Dean Thomas Schwenk, MD, in an editorial accompanying the article in JAMA. Dr. Schwenk also noted that the current training environment makes it clear that residents aren’t supposed to stay home when ill or ask for coverage when a child or parent needs them or express any vulnerability in the face of overwhelming emotional and physical demands. Many residents also see their superiors as “monsters,” which was demonstrated in a Comics in Medicine class at Penn State College of Medicine, where students drew comics that portrayed their supervisors as fiendish, foul-mouthed monsters and themselves as sleep-deprived zombies, according to another article in JAMA. According to Dr. Schwenk, today’s frantic environment leaves little time for benevolent types of supervision and teaching for d o c t o r s - i n - t ra i n i n g , and it’s time to swing the pendulum back toward more personalized training and toward dedicated teaching and mentorship.

IMPROVING PATIENT INTERACTION TRAINING

Changes in the medical education landscape are also driven in large part by patients who expect doctors to listen to them and to be more sensitive to their needs. Medical schools’ need to train doctors to improve bedside manners will become increasingly important as doctors and hospitals face being rewarded and paid based on providing value-driven and quality care. And many medical centers nationwide are striving to do just that, according to Kaiser Health News, admitting that much of the effort is fiscally driven but small changes have shown to go a long way in terms of patients expressing satisfaction, complying with recommendations and taking medicines. Among the efforts are Partners HealthCare in Massachusetts and medical schools such as Duke that re-

MEDICINE: STILL A MAN’S WORLD

The need to hire and promote more female doctors is also getting attention, not only in order to narrow the gender gap in medicine, but also to open the door to more doctors able to relate to patients in more personal ways. Two studies suggested that “medicine is still a man’s world,” despite nearly half of all medical school graduates being women. A study that analyzed 90,000 doctors’ records found that men are 15 percentage points more likely to have the rank of full professor than are women. Women generally produce less research than men, the study added, which suggested that they may have less mentorship and less institutional support than their counterparts. The study was published last September in the medical journal JAMA.

T H E C H ANGING FAC E OF M EDIC AL EDU C AT ION | F EAT U R E

quire residents to take courses to be more empathetic, encouraging them to write personal details such as hobbies and sports teams into medical charts to encourage bonding and to write follow-up notes and make follow-up calls to patients.

The study also found that women in medicine and science are paid less, have higher rates of attrition, fewer scientific publications and are less likely to apply for National Institutes of Health funding and be principal investigators compared to men in the same profession. The concern here is also that it leaves patients with less doctors they can relate to in terms of race, ability or sexual orientation, the study researchers noted. Teaching medical professors to “mentor across boundaries could help,” the researchers noted.

CONCLUSION

With a revolution in how healthcare is delivered and paid for, schools that train doctors are scrambling to revamp their efforts to adapt to the new system. Meanwhile, technology-savvy residents are having a greater say in the terms of their residency programs, benefits, and pay, and are expressing their desire for more benevolent training and mentorship. And a need to add more women to the physician rosters is emerging as a major concern as the world of medicine moves forward.

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TOP 3 PATIENT SAFETY TIPS:

Reducing Technology Risks BY CAROL MURRAY, RHIA, CPHRM, CPPS, PATIENT SAFETY RISK MANAGER, THE DOCTORS COMPANY

The adoption of electronic tools in the patient care setting has grown exponentially in recent years. Although new technologies bring many benefits, they also bring new liability risks—and 2015 could be considered a high-water mark for both new risks and increased prevalence of previously identified risks. The top three patient safety tips of 2015 addressed these risks: TELEMEDICINE | Comply with HIPAA, HITECH, and

state-specific laws when transmitting patient health information, and follow state licensing requirements. While the benefits of telemedicine are vast, its use and adoption must be tempered with caution. Physicians must be aware of the risks associated with access, such as patient and staff privacy, inaccuracies in self-reporting, and symptoms that may only be caught in person. Additional legal considerations for online interactions, such as licensure compliance and professional liability coverage for out-of-state interactions, must be addressed for the protection of the physician and the patient. According to the Federation of State Medical Boards, only 12 states have provided special-purpose licenses to allow for cross-border telemedicine, while most states require complete licensing if the patient is in their jurisdiction. To reduce these liability risks and enhance patient safety: • Comply with all laws when transmitting all personal health information. Train staff on how to protect and secure your data. • Clearly define proper protocols for webcams and web-based portals. • Use mechanisms to protect the privacy of individ1 4 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2016

• •

uals who do not want to be seen on camera (including staff members, other patients, or patients’ families). Ensure robust and reliable high-speed broadband connectivity to support clinical functions. Check practice requirements and legal limitations in states where you anticipate providing care to patients. Understand reimbursement practices for telemedicine services. Make certain that your professional liability policy extends coverage to all jurisdictions where you provide services.

MEDICAL EQUIPMENT ALARMS | Enact policies to en-

sure alarms are never silenced. Concerns about the adequacy and effectiveness of medical equipment alarms have been a focus for The Joint Commission’s National Patient Safety Goals. Issues with alarms have also appeared frequently in analyses of unanticipated outcomes. A main patient safety risk is alarm fatigue, where too-frequent alarms cause providers to override or disable them. When alarms are silenced or eliminated, a sig-

• Policies should be in place and communicated to staff to never silence an alarm and should discourage the use of patient-owned medical equipment without alarms in clinical settings. • Any medical device equipped with an alarm should be evaluated annually for preventive maintenance. ELECTRONIC HEALTH RECORDS (EHRS) | Ensure that

implementation includes thorough staff and provider training. More than 80% of doctors have adopted an EHR.1 There is a lag time between adopting a new technology and identifying risks, but in 2015, EHR issues were increasingly apparent. Weaknesses include inaccurate entries that are repeated throughout the record; faulty interfaces between companion systems; greater potential for breaches, resulting in loss of patient privacy; over-reliance on the system by staff, leaving less time to spend with patients; changes in medical record information due to system updates; and difficulty in standardizing the legal medical record for consistency in response to requests for records. Audit trails requested during litigation may not accurately reflect the activity or may be undecipherable. Some systems allow changes in record entries long after a patient is seen—if that is discovered, this could be interpreted as spoliation of evidence. To reduce exposure to EHR risks: • Ensure implementation includes thorough staff and provider training.

• Conduct medical record audits at least quarterly to look for any possible problems. Increasing attention is also directed at the integrity (accuracy) of data entries in the EHR. Weaknesses in data integrity can and have resulted in erroneous treatment or delays in the discovery of new and vital information. More and more related systems have an interface with the EHR, such as laboratory or imaging information, other healthcare encounters, medication history, and even basic demographic information. It is not uncommon for data in the EHR to be inaccurate or missing. Problems such as errors in entering treatment regimens can have far-reaching outcomes. While there is a strong emphasis on interoperability of systems, there are also many problems in perfecting the interface. As the assimilation of medical technology increases at a faster rate, all providers and organizations must closely scrutinize these systems to discover issues and problems before they reach the patient. Training staff and physicians and ensuring solid communication models are the most valuable ways to reduce patient safety risks. _________ Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety. Reference: 1More than 80% of docs use EHRs. Healthcare IT News. September 18, 2015. http://www.healthcareitnews.com/news/ more-80-percent-docs-use-ehrs. Accessed November 23, 2015.

MEDICAL BOARD HOSPITAL STAFF F R A U D / A B U S E MEDI-CAL/M E D I C A R E

MEDICAL PRACTICE PURCHASES, SALES AND MERGERS

• Establish guiding policies and procedures, especially a policy defining the legal medical record, and designate an ongoing workgroup or individual to address problems in either support systems or the software itself. • Maintain an ongoing relationship with the vendor to communicate software issues and to thoroughly understand the impact of each software update. • Conduct a periodic review of metadata reports that identify name, date, and time of access—a useful way to monitor inappropriate access to the record by staff. • Train staff to be observant and report any inconsistencies, including a nearmiss or incident.

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nificant change in a patient’s condition may go undetected. If there is a resultant harm to a patient, it is extremely difficult to mount an effective defense. The Joint Commission emphasizes policies that can help reduce the risks:

AT WORK F OR Y OU | U NIT ED WE S TAN D

Updated Prescription Drug Monitoring Program Up and Running CMA OFFERS TECHNICAL ASSISTANCE FOR CURES 2.0 USERS

Because more Americans die from prescription opioid overdose than in drunken-driving car crashes, according to data from the Centers for Disease Control and Prevention, a systemic change in how healthcare providers prescribe certain medications is needed to address prescription drug misuse in the U.S., according to research published recently in JAMA Internal Medicine, Kaiser Health News reported on Dec. 14.

The new CURES 2.0 system will include the release of a streamlined registration process, and will enable users to apply for access and verify their credentials entirely online.

On January 8, 2016, the California Department of Justice (DOJ) launched an upgrade to the Controlled Substance Utilization Review and Evaluation System (CURES), California’s prescription drug monitoring system. Known as “CURES 2.0,” the system promises a significantly improved user experience and features a number of added functionalities. The database will enable healthcare providers to review medication histories before prescribing new drugs. The system was created to stop overdoses and prevent the illegal sale of prescription drugs. It also will help stop patients from getting narcotics from multiple physicians or taking dangerous combinations of medicines. The new 2.0 system will include the release of a streamlined registration process, according to a Dec. 22 report by YubaNet. It will enable users to apply for access and verify their credentials entirely online, using secure web browsers. The upgraded system features analytics for identifying at-risk patients. Not everyone has been enthusiastic about the new system. Implementation has been delayed six months after the California Medical Association said it would be incompatible with its own computer systems. Association officials are hopeful that problems have been resolved. The CURES sign-up deadline for health practi-

1 6 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2016

tioners licensed to prescribe or dispense scheduled medications is July 1, 2016. All users who log into CURES will be prompted to update their security information in order to confirm their account. Those users who meet specific web browser compatibility requirements will be directed to CURES 2.0, while others will be routed to the old CURES 1.0 interface. After following this security step, physicians may experience a 15-to-20-minute wait before being able to log into the system with their updated credentials. Physicians who encounter technical difficulties – such as logging into their accounts, retrieving their log-in information or verifying their accounts – should contact the DOJ CURES Help Desk at (916) 227-3843 or cures@doj.ca.gov. Providers are also encouraged to report these technical issues to the California Medical Association’s member help line by calling (800) 786-4262 or emailing memberservice@cmanet.org. All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate must be registered to use CURES no later than July 1, 2016. To register using the new automated system, visit http:// oag.ca.gov/cures.

The California Medical Association (CMA) has published new legal guidance intended to help physicians and patients understand the End of Life Option Act, which was passed in 2015 and makes physician aid-in-dying legal in California. The document is in a question-and-answer format, and is intended to help both physicians and patients navigate the complicated law. “As physicians, there are a lot of questions about requirements under the new law, required documentation and forms, requests for the drug, consulting physicians and so on,” said CMA President Steve Larson, MD “There certainly will be areas that evolve as we look to best practices in areas like which drugs to prescribe, but this is a resource to help us all navigate the new landscape.” Throughout the 15-page document, both straightforward questions as well as those without answers yet are included, and acknowledge that the resource will evolve as the law goes into effect. CMA’s health law library is the most comprehensive health law and

medical practice resource for California physicians and contains On-Call documents with up-to-date information including current laws, regulations and court decisions related to the practice of medicine. On-Call documents are generally a benefit for CMA members and are available for sale to the public; however, On-Call document #3459, “The California End of Life Option Act,” is free through CMA’s website. “CMA was fielding calls from not only our members, but the general public about what the End of Life Option Act means and how it will impact care moving forward,” said CMA General Counsel Francisco Silva. “This is a complicated issue and both physicians and patients should have access to answers that help further the patient-physician relationship.” CMA removed longstanding opposition to physician aid-in-dying last May and took a neutral position on the End of Life Option Act, Senate Bill 128. Contact: CMA Legal Information Line, (800) 7864262 or legalinfo@cmanet.org.

F EB RUA RY 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 17

U NIT ED WE S TAND | AT WORK F OR Y OU

CMA Publishes Physician Guidance for End of Life Option Act

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