January/February 2015

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

DISASTER PREPAREDNESS IN SAN FRANCISCO Social Media in a Disaster Lessons from the Asiana Airlines Accident How to Get Involved Ahead of Time Securing Our Blood Supply

Introducing the 2015 SFMS President, Roger Eng, MD

Plus: CMA House of Delegates

VOL.88 NO.1 January/February 2015

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

January/Februry 2015 Volume 88, Number 1

Disaster Preparedness in San Francisco FEATURE ARTICLES

MONTHLY COLUMNS

10 Preparedness in the Public Arena: Medical Oversight in EMS

in Disaster Planning for Special Events

John F. Brown, MD, MPA, FACEP

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Membership Matters

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Introducing the 2015 President: Q&A with President Roger S. Eng, MD, MPH, FACR

12 Lessons from #hellastorm: Using Social Media in the Event

of an Emergency

Kristin Hogan 14 Get Involved Ahead of Time: Disaster Response

Opportunities for Medical Professionals

Rebekah Varela and Naveena Bobba, MD, MPH

15 Donating Blood: A Vital Aspect in Preparing for Disasters

Kent Corley

17 The Asiana Airlines Accident: Mass Casualty Response and

the Future of Emergency Care

John Maa, MD 19 Ambulances in San Francisco: The State of Emergency

Medical Services

Sebastian Wong

Editorial Gordon Fung, MD, PhD

20 Medical Community News 21 Classified Ad 26 Upcoming Events

OF INTEREST 21 Measels Update from the SFDPH 23 Health Policy Perspective: Single-Payer

Dreams—and Realities

Jack Lewin, MD

24 CMA House of Delegates Report

Gordon Fung, MD, PhD, and Steve Heilig, MPH

Welcome New Members

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

PHYSICIANS Cathleen Nora Cabansag, MD | Internal Medicine Alice Huan-Mei Chen, MD | Internal Medicine Ellen Huan-Lun Chen, MD | Family Medicine Mark David Garfield, MD | Pulmonary Critical Care Medicine Catherine Teresa James, MD | Family Medicine Stephanie Jo Jeske, MD | Hematology Oncology David Gregory Kornguth, MD | Radiation Oncology Andrew I. Lu, MD | Gastroenterology Timothy Hugh Mccalmont, MD | Dermatopathology STUDENTS Nancy Nasrawin

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

New Reassignment of Medicare Benefits (855R) Enrollment Form The Centers for Medicare and Medicaid Services (CMS) finalized a new 855R form, which is used to reassign an individual physician’s Medicare billing privileges to an organization. The revised form is available on CMS.gov.

Medicare administrative contractors will accept both the current and revised versions of the form through May 31, 2015.

The new version must, however, be used for applications received by the Medicare Administrative Contractor on or after June 1, 2015. Prior versions will be denied. The online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) will be updated to include the revised Medicare reassignment information.

the award on December 6, 2014, at the annual President’s Reception and Award Gala, hosted by the California Medical Association Foundation.

2015 Medicare Benefit Changes

Each year, the Centers for Medicare and Medicaid Services reviews and determines what changes are needed for deductibles, premiums, and other Medicare program limitations. The Medicare Physician Fee Schedule for January through March 31, 2015, has been posted to the Noridian website (http://bit. ly/1tONe3W). Changes in Relative Value Units (RVU) for malpractice, work values, geographic practice index values, and others may have an impact on the amount paid. Please check the updated fee schedule for any changes. Changes necessitated by legislative decisions made during the first quarter of 2015 will be posted as they become available.

Physician Practices Urged to Verify Patients’ Eligibility and Benefits in 2015

SFMS Member Receives CMA Foundation’s Access to Health Care Award Editor of San Francisco Medicine Gordon L. Fung, MD (pictured above), was selected as the 2014 recipient of the CMA Foundation’s Adarsh S. Mahal, MD, Access to Health Care and Disparities Award. Dr. Fung is a cardiologist and the director and founder of the UCSF Asian Heart and Vascular Center, the first center in the Bay Area focusing on the specific cardiovascular needs of Asian Pacific Islanders.

SFMS nominated Dr. Fung in recognition of his ongoing commitment to improving health care access for the San Francisco Bay Area’s Asian community. Dr. Fung was presented with 4

SFMS is advising physician practices to be diligent in verifying patients’ eligibility and benefits to ensure reimbursements for services rendered. The beginning of a new year means calendar-year deductibles and visit-frequency limitations start over.

With open enrollment, there may also be changes to patients’ benefit plans, or they may even be insured through a new payor.

The new year also brings a host of other challenges that could impact physician reimbursements: Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage, or switch from one Advantage plan to another.

The Covered California open enrollment period is November 15, 2014, through February 15, 2015. Existing exchange/ mirror patients have the option to select a different plan, and Covered California expects an additional 500,000 individuals will enroll in an exchange plan during the 2015 open enrollment period.

There will be some changes to exchange/mirror product names in 2015. Covered California notified all exchange plans that the product names must be the same for exchange and mirror products and that plans must also use a standard naming convention for all individual exchange/mirror products.

The 2015 Covered California QHP naming convention is as follows: [carrier name] + [metal tier name] + [Actual Value] + [product type (e.g., EPO, HMO, PPO)] Example: Blue Shield Bronze 60 PPO

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

SFMS Membership Expires December 31; Renew Your Membership Today SFMS would like to thank our 1,600+ members for their support of the local medical society this year. Because of your support and participation in organized medicine, SFMS continues to be the preeminent physician organization championing the cause of physicians and their patients as we face the many challenges of these changing times.

Please take a moment to renew your support of SFMS by remitting payment for your 2015 dues today. There are three easy ways to renew your dues again this year: • Mail/fax in your completed renewal form.

• Renew online at sfms.org using your credit card.

• Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.

Covered California Launches Second Enrollment Period

As of January 11, 2015, 217,146 California residents had signed up for private coverage during the Covered California’s second enrollment period.

The state health insurance exchange will close enrollment on February 15, 2015. SFMS has developed an online resource center to help educate physicians and practice managers on the exchange and ensure that they are aware of important issues related to exchange plan contracting at http:// www.sfms.org/ForPhysicians/CoveredCalifornia.aspx.

CMA Files Brief in Medicaid Case to be Heard by the U.S. Supreme Court

The California Medical Association (CMA) has filed an amicus brief in a Medicaid reimbursement case (Armstrong v. Exceptional Child Center) that will go before the U.S. Supreme Court this year to determine whether Medicaid providers have a cause of action under the Supremacy Clause of the U.S. Constitution to challenge a state’s compliance with Medicaid laws in setting reimbursement rates. The Medicaid Act’s equal access provision requires that states must reimburse providers at a level high enough to attract enough providers to participate so that enrollees have the same access to care that private pay enrollees have in the same geographic area. The ability of providers to sue under the “supremacy clause” has been tested in many states that have tried to reduce Medicaid reimbursements in response to budget constraints. There is no federal guidance on how reimbursement rates should be determined.

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January/February 2015 Volume 88, Number 1 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD Payal Bhandari, MD David Pating, MD SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young

BOARD OF DIRECTORS Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

WWW.SFMS.ORG

JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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INTRODUCING THE 2015 PRESIDENT Q&A with President Roger S. Eng, MD, MPH, FACR

Dr. Roger Eng is a board-certified radiologist and president of Golden Gate Radiology Medical Group.

He is a fifth-generation Chinese American and third-generation San Franciscan and currently serves as the chief of Radiology at the Chinese Hospital and Integrated Healthcare System, a nationally recognized award-winning health care model delivery network providing cost-effective and culturally competent health care for more than 60,000 San Franciscans.

Dr. Eng has had extensive leadership experience in organized medicine. He is the immediate past president of the California Radiological Society, has served on the California Medical Association (CMA) Board of Trustees as well as other CMA committees, and was recognized by the American Medical Association as the top U.S. resident for community service leadership during his medical training.

Dr. Eng earned his medical degree and a master’s in public health in administrative medicine and health policy from George Washington University; he earned a bachelor of arts in genetics from the University of California, Berkeley.

When not in practice, Dr. Eng enjoys chasing down his four boys (having changed diapers for twelve consecutive years), hiking, and traveling with his family to any park with Mickey Mouse.

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Connect with Dr. Eng via Twitter @RogerEngMD or send him an email at reng@sfms.org.

Dr. Eng recently sat down with San Francisco Medicine to share his viewpoints on the role of organized medicine and physician advocacy.

Why are you a member of SFMS?

When I joined in 1994 as a resident, I believed then—and still believe now—that physicians need organized medicine to represent and advocate on their behalf with insurance companies, legislators, and public policy. As much as we work to heal individual patients, our ability as a physician to affect macro health issues is limited. SFMS is the only physician organization in San Francisco that represents physicians across all specialties and practice settings. Together with the CMA, we are the largest physician organization in San Francisco and California and are seen as the voice of medicine in City Hall and Sacramento.

Why is being an active member in organized medicine important for your patient-care philosophy?

For 146 years, SFMS has been there to faithfully champion

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

quality health care and innovation for our patients and community. It serves the professional needs of all San Francisco physicians. SFMS has often led the way with health initiatives that benefit our patients and our profession, including banning soda from public schools and regulating e-cigarettes.

We saw a textbook example of the importance of organized medicine in the 2014 election. SFMS and CMA successfully led a diverse coalition to defeat Proposition 46, which would have negatively impacted health care access and undermined the physician profession.

One of my mentors, past SFMS and CMA President Rolland Lowe, MD, once said, “When drinking from the well, remember the source”. I believe it is part of our mission as physicians to serve the larger community that supports us. There is no better means to achieve this than through involvement in the SFMS and CMA, which amplifies the voice of physicians via our network of more than 1,600 locally and 40,000 statewide. This is why I continue to participate in and support SFMS/CMA advocacy efforts; to ensure that physicians remain in control of medicine and provide quality health care to our patients.

Can you tell us about any goal(s) you hope to accomplish in your new position as SFMS president?

The coalition of patients, doctors, and hospitals working together in the last election showed us how extremely successful a united team can be. I’m so proud of our membership for stepping up and taking a lead in this fight. I hope to continue this momentum to tackle other objectives such as improving health care access and facilitating collaboration among San Francisco’s disparate medical services.

Relevancy to the local medical community is a key priority for SFMS this year. SFMS has been successful in utilizing social media such as Twitter and LinkedIn to engage physicians.

We plan continue to expand its use to better reach out to all our members, especially our medical students, residents, and young physicians.

What are some of the biggest opportunities or challenges you see in health care within the next year?

Health care is in the midst of a once-per-generation transformation. EHRs, health care integration, technological disruptors, industry consolidation, and the ACA will continue to affect our practices. While more of our patients are now covered by some form of insurance, there continues to be affordability pressures for patients and reimbursement issues for physicians.

SFMS will continue to be a clearinghouse of resources for “all things San Francisco medicine” to local physicians. Our goal is to make it easier for physicians to practice quality medicine and navigate the ever-changing health care environment through our physician tool kits, advocacy efforts, and active member information-sharing network.

How do you balance your work and personal life, and still manage to find time to participate in SFMS activities?

I am truly blessed with four children and an amazing wife who keeps it all together. Her generosity of spirit inspires all WWW.SFMS.ORG

Dr. Eng (far right) with SFMS at 2014 CMA Legislative Lobby Day who meet her. Together they keep me grounded and remind me of life’s priorities. They are complemented by our extended family that looks over us.

Any advice for new physicians transitioning into practice from residency?

Find a practice that best fits your personality and cultural identity. Salary and benefits are important, but rarely have I seen doctors change positions solely because of this. Physician satisfaction is often dependent on intangible factors such as work-life balance, practice style, and practice culture.

Transitioning from the ivory-tower setting of the typical residency to private practice can be a big culture shock. The expectations of a group practice are different, with new skill requirements in medical administration, billing, coding, regulatory, HIPAA, etc. The local Medical Society is an excellent way to network within the medical community, while their webinars and educational tools help young physicians learn these new skill sets all practices will value.

What about you would surprise our members?

My family was one of the first families of Chinese ancestry to settle in America. A small fleet of junks (small Chinese sailing vessels) crossed the Pacific from Southern China and landed in Monterey Bay. This was in 1852. They were fisherman and farmers, and in the early 1900s they could send a crate of lettuce by rail to New York City in two days. A photo of that family farm hangs in my office as a reminder of my roots.

Serving as SFMS president is continuing a legacy of community service. My grandfather was the first Chinese American U.S. Deputy District Attorney. My father is the former mayor of Los Altos. And my uncle is Dr. Edward Chow, president of the San Francisco Health Commission and a former SFMS president.

If you weren’t a physician, what profession would you most like to try?

I love what I do, but if we are thinking alternative realities here, I would find it interesting to work at a company like Disney. In fact, my whole family could get in on the act. My sports-fanatic wife can guest-anchor ESPN Zone. My kids will graciously act as alpha and beta testers for any new amusement rides created. And I could let my imagination run wild, delighting millions of children and creating new Star Wars and Marvel theme parks.

JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD

Disaster Preparedness: Are You Ready to Pitch in?

Do You Know What to Do? As a third-generation San Franciscan and a second-generation physician, I have lived with the constant

and now increasing warnings that a sizable earthquake—a natural disaster—is coming, and the new West Coast line may be Nevada. I remember doing earthquake drills when growing up in public schools, when all the students would run to seek shelter underneath their tables as the teacher stood under the doorframe, where it was supposed to be safer due to the construction of doorframes. We were also taught not to go outside, where glass and bricks could fall from buildings.

Since those drills I don’t remember any formal training or drills to prepare the community for responding to disasters.

I distinctly remember not having any formal training in high school, undergraduate school, or medical school on how to react or what to do in a city, regional, or statewide disaster.

We weren’t even taught first aid until we did our emergency department rotation. It wasn’t until I formally completed my medical training and was applying for medical staff privileges at the various hospitals that I was informed and instructed through the emergency preparedness plans for each hospital that I worked in as to my duties as a medical staff member and on how I should respond to a crisis with respect to the hospital. It was particularly difficult for me and for those of my colleagues who had medical staff privileges at multiple hospitals, since one could never predict where one would be when a major disaster struck.

As a member of the Institute of Medical Quality Hospital surveyor team, when I go to different hospitals, I review their emergency plans to see if they educate their medical staff on the appropriate response to disasters and how to coordinate care with the designated hospital physician in charge. Further, if you don’t even have privileges at the nearest hospital, you need to know how to present yourself with the appropriate credentials to be helpful. With today’s medical practice environment, there is a significant push to have each and every medical office and practice, whether it is solo or group, be prepared as a site that can deliver first aid or direct people to the right place to receive medical attention. This is a significant undertaking for all medical practices in disaster-prone areas—such as San Francisco, with its earthquakes, threats of Ebola or other infectious diseases because we are a major site for travel, or plane crashes given our airports.

As we have all come to learn, preparing for disasters and the correct response from the medical community needs to be a coordinated effort across all responsible systems, including the EMS; public health services, hospitals, medical clinics, and offices; the transportation systems; the communications WWW.SFMS.ORG

systems; and all suppliers of food and aid. Schools, businesses, skilled nursing facilities, and senior centers also need to be involved, given their sizable and vulnerable populations.

The City of San Francisco has been preparing for the next big earthquake and has many response plans in place. During this time of preparation we have been tested with other disasters, and the lessons we have learned from each disaster have helped prepare us for each subsequent event. Unfortunately, when emergencies and catastrophes strike, they don’t give warning. The best earthquake alert system can only foretell an earthquake by about 30 seconds and then sound the alarm. When the Asiana Airlines crash occurred, even though the plane was coming in at a very low altitude and appeared to be headed for certain disaster, no alarms were sounded until the crash occurred.

In this edition, we are fortunate to recruit experts in the field of emergency medicine and disaster preparedness to discuss some of the events that we need to be aware of when preparing for and responding to disasters. Heading up the list is Dr. John Brown, medical director of the San Francisco Department of Emergency Management. He discusses the emergency preparations that should go into any major event. We have major events all year long, frequently overlapping and crowding the weekend calendars in selected months. Kristin Hogan discusses the use of social media during a disaster for communications. She also discusses the built-in routes of contact for services and communications set up by the City for the entire City and County. Rebekah Varela and Naveena Bobba, MD, MPH, provide a quick primer on what to do now as you are thinking about preparing for the next disaster. For those of you who have already done this planning, use it as checklist to make sure your plans are complete with all the up-to-date contact information that will be needed. Kent Corley reminds us not to forget about the most important ingredient during a major disaster: the blood supply. It is usually too late to respond to the blood bank during an emergency. This needs to be on everyone’s planning list so that the city can respond with adequate stores of needed blood. Dr. John Maa, a general surgeon and San Francisco Medicine editorial board member, gives his perspective on the most recent disaster response, in which the entire city performed admirably. There were many near misses and pure-luck events, and that incident taught us many lessons. And Sebastian Wong, head of the emergency ambulance system, gives us the current state of the response system that we count on in the field to assess the disaster and bring the injured and needy to care.

JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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Disaster Preparedness in San Francisco

PREPAREDNESS IN THE PUBLIC ARENA Medical Oversight in EMS and Disaster Planning for Special Events John F. Brown, MD, MPA, FACEP San Francisco is a city known the world over for a wonderful climate; breathtaking natural scenery; tourist and cultural attractions, such as the Embarcadero, AT&T Ballpark, and the S.F. Opera; and a diversity of cultures and viewpoints that produce public events and celebrations of many sizes and shapes. Over the years we have been fortunate to have single special events of community-wide significance—the recent America’s Cup competition and World Series Championships are good examples—and many recurring neighborhood celebrations ranging in size from neighborhood block parties to the LGBT Pride Parade and fair. Each of these gatherings has the potential for untoward escalating events, and the medical oversight for them must range in scale from EMS responses for individual patients to triage capability and the capacity to sort large numbers of ill and injured patients and prioritize their care.

The San Francisco EMS Agency has a policy requiring medical planning for special events or mass gatherings of more than 2,500 participants, staff, and spectators. These plans vary in complexity and capacity to deliver medical care depending on the type of event, the number of attendees, the duration and location, and the prior history of recurring events. Those events with higher risk, such as endurance athletic events, require the capability for advanced life support medical care as delivered by physicians, nurses, and paramedics present at the site. The ultimate goal is to provide the same level of emergency medical services, or EMS, that a participant or bystander would get if the event were not being held and normal 911 services were covering the area.

This type of planning bridges the gap between day-today emergencies and disaster medical care. Since most special events generate crowds of people in venues not routinely accommodating them, there is often little or no infrastructure in place. Most large-event venue buildings, such as AT&T and the former Candlestick Park, the Moscone Convention Center, the Bill Graham Civic Auditorium, and even the San Francisco Opera, have routine medical care facilities that activate during the hours when large numbers of people congregate there, and then downsize during quiet times. Outdoor and mobile events, however, have no regular medical coverage except 911 EMS service, which can be strained on a day-to-day basis and is not designed to have sufficient surge capacity to deal with regularly scheduled mass gatherings. These events can also have a negative impact on the areas surrounding them and outside the “footprint” of their activities, which can stress EMS resources and decrease the ability of providers to respond adequately to a disaster.

Many examples exist in California, as well as other areas of the country and the world, of special events that became multicasualty incidents, both from factors potentially within the control of event planners and from outside factors. An example of 10

the former situation was a papal mass held in Denver, Colorado, on August 12, 1993, when patients were treated for hypothermia from an all-night vigil preceding the event, then patients were treated for heat exhaustion and dehydration due to high daytime temperatures during the event and inadequate toileting facilities due to underestimates of crowd attendance. An example of the latter situation was the Boston Marathon bombing of April 28, 2013, when 264 injuries and four deaths resulted from the act of terrorist violence by two individuals not associated with any known threat groups.

In all such circumstances, scene management to mitigate the effects of the event and prevent further injury and illness takes priority over medical care. The standardized Incident Command System, which provides for unity of command and appropriate scope of management, needs to be quickly implemented.

Medical treatment is provided by the Medical Group in the Operations Branch and needs to be quickly assembled with triage, treatment, and transport functions. This can be started within a matter of minutes and then scaled up or down to meet the needs of the event as well as the resources devoted to it. Some events with no-notice, maximal impact (the July 6, 2013, Asiana airplane crash at San Francisco International Airport is a good example) have an initially minimal response that rapidly escalates until immediate needs are met, then rapidly de-escalates.

Other events, such as the Ebola Virus Disease response in the United States, have slower initial development but have ongoing needs that incur continuing response and system improvement.

A common theme between special events and disaster medical responses is the need for clear, constant, and reliable/redundant communication.

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

Essential communicators are the event command center; the medical treatment area; the transportation function; the 911 dispatch center; and, in events where a government response is mounted, the Emergency Operations Center. The tools used are usually EMS-encrypted radios but can include cell phones (frequently overwhelmed in larger special events by participants, especially if disaster strikes), other handheld radios, Internetbased communications tools such as the San Francisco EMS Agency’s new Reddinet system, and satellite telephones. Social media is being used on a regular basis by members of the community to document mass gatherings and disaster events, so responses need to have a social media presence and awareness, as public behavior is modified by this communication tool (see the article on social media in disasters on page 12 of this issue).

Post-event recovery and a return to normal operations (continuity of operations) is the last phase of both special-event and disaster emergency medical care. Personnel rest/rehabilitation, replenishment of supplies, restoration of the pre-event physical condition of the venue, and after-action reporting are common elements. After-action reports, which document observations of the event needs and care provided, are useful research and historic tools but are only truly useful if lessons learned and recommended changes are implemented. Similar to hospital morbidity and mortality reviews, they are best conducted with data from the event as close to its conclusion as achievable, with participants in the event being present, and with an eye toward finding and improving system problems. Frequently the “feedback loop”

is left unclosed, so it is important for emergency providers to both read these recommendations and train/exercise to fulfill them in order to get the full benefit of the evaluation. Even if not otherwise involved in a special event or disaster medical response, we as physicians can learn from each other’s experiences and make these events safer and more medically sound for all.

John F. Brown, MD, MPA, FACEP, is the medical director of the San Francisco Emergency Medical Services Agency, a position he has held since 1996. He is board certified in both emergency medicine and EMS medicine. He is also an associate clinical professor of Emergency Medicine at UCSF Medical School, and an attending physician at SFGH and Trauma Center, where he directs the EMS/Disaster Fellowship program. He is a medical officer for Disaster Medical Team CA-6, the Bay Area’s volunteer medical team for the National Disaster Medical System. He is a member of the SFMS.

Connect with SF Department of Emergency Management on Twitter, @SF_emergency, or visit them online, www.sfdem.org.

With speaker Malcolm Gladwell author of The Tipping Point Including speaker Siddhartha Mukherjee, M.D., author of The Emperor of All Maladies: A Biography of Cancer

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Disaster Preparedness in San Francisco

LESSONS FROM #HELLASTORM Using Social Media in the Event of an Emergency Kristin Hogan With a much-needed deluge of rain in the San Francisco Bay Area came a unique opportunity: to bond over

the weather and to get excited about getting ready for emergencies. Monday, December 8, 2014, the San Francisco Department of Emergency Management (SFDEM) kicked off its week focused on the weather, and what was being forecast as the biggest winter storm to hit the Bay Area since 2008. There was little doubt that we would activate the City’s emergency operations center, as a storm of this significance would likely cause myriad challenges such as flooding, power outages, and transit disruptions, to name a few. Meanwhile, the City took some tactical measures to get ready for the storm, including assigning crews to work for days to make sure catch basins were clear and to provide sandbags to the public. While seeing a very energized San Francisco community rallying around the storm on both traditional and social media, SFDEM jumped in not only as a government agency whose primary responsibility is to ensure that all emergency response organizations work together in a coordinated and effective way but also as a fellow member of the San Francisco social networking community.

What we found was that San Franciscans were eager for emergency preparedness messaging that otherwise is overlooked. Recognizing this opportunity to deliver both storm and general preparedness messages to a primed audience, SFDEM’s public information team developed hyper-local storm preparedness messages mixed with pop culture references, beginning with a DEM blog entitled Winter Is Coming (a reference to the popular HBO show Game of Thrones), designed to inspire a dialogue about the storm and how to be prepared for it. We promoted this blog on our social media channels, which include Facebook, Twitter, and—new to the mix—Nextdoor, a social network for San Francisco neighborhoods. The response was phenomenal, especially on Nextdoor, with accolades directed toward SFDEM for being not only socially in tune but for providing timely storm preparedness (and general emergency preparedness) information.

Our messages were simple yet clear, and they specifically included the following:

Core Message

There are simple ways to get ready for this storm, stay safe, and help prevent flooding.

Key Messages

• Sweep up leaves and litter from sidewalks and gutters and place them in the appropriate bins. This can help keep storm drains from getting clogged.

• Anywhere it rains it can flood, especially if you live in a lowlying area.

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• Construct barriers to stop floodwater from entering your home or building.

• The San Francisco Department of Public Works offers free sandbags to protect your property. http://sfdpw.org/index. aspx?page=1810 • If water has entered a garage or basement, do not walk through it. You can’t always see or smell what’s in the water and it could be harmful to you.

• Walking through moving water is dangerous. Six inches of moving water can make you fall. If you must walk in water, walk where the water is not moving. Use a stick to check the firmness of the ground in front of you.

• Stay clear of water that is in contact with downed power lines.

• Keep children from playing around high water, storm drains, or any flooded areas.

• Secure patio furniture to prevent potential projectile damage in high-wind conditions.

• Do what you safely can to keep drains and downspouts clear of leaves, branches, etc., that could block water flow and lead to localized flooding.

• Cover windows with heavy-duty plastic or temporary wood coverings to minimize risks from flying tree branches in highwind conditions.

• Flooding can also cause headaches on roadways. The following are important points to remember when driving in flood conditions: • Six inches of water will reach the bottom of most passenger cars, causing loss of control and possible stalling. A foot of water will float many vehicles.

• Avoid driving through flooded roads. The depth of water is not always obvious and you could be stranded or trapped.

• Barricades are there for your protection. Turn around and go the other way.

• Be especially cautious driving at night, when it is harder to recognize flood dangers.

• Review your emergency supplies. Do you have batteries for your flashlights just in case the power goes out? Visit www.sf72. org/supplies for more ideas.

• To report rain-related issues call 3-1-1; If you are in danger or have an emergency call 9-1-1. [Note: For future severe weather public information messaging, include contacting Pacific Gas and Electric Company for power outage information: 1-800-PGE5000.]

• For more information, call 3-1-1 or follow @sfpublicworks and @sf_emergency on Twitter. You can also visit sf72.org/em/ home or 511.org for additional road-closure and other safety information.

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

During the storm • We can do smart, practical things to stay safe and relatively dry [refer to aforementioned key messages].

• If the power goes out, unplug and turnoff appliances and leave one light on so that you know when the power comes back.

Avoid using candles—they are fire hazards, especially in San Francisco.

• Check CityNow (or Crisis Map) on SF72.org. This is an existing feature on SF72 that becomes our home page during emergencies.

We continued the storm-related emergency public information messages throughout the storm itself, with blogs on poweroutage safety; and we continued the Game of Thrones reference with a blog entitled Winter’s Here: Now What?, which focused on celebrating San Franciscans for being more prepared than they were before the storm and drove home general emergency preparedness messages. Another strategy SFDEM’s public information team used was monitoring trending hashtags, the most frequently used of which was #hellastorm (hyper-local as it played on the Bay Area slang word “hella”).

Why is #hellastorm a case study for us? Here’s the thing: When there’s an emergency of city-wide significance (which could range from something like #hellastorm to the Napa Earthquake), our target audience is primed and ready for preparedness information that otherwise is overlooked. Our original Twitter account (@SF_emergency) has more than 70K followers, and they are very clear that they primarily follow us for emergency notifications, alerts, and warnings. In fact, we have received direct feedback from several followers that they consider any emergency preparedness tweets to be spam . . . except when there’s a collective emergency. And that is why we strike when the iron is hot (so to speak) and deliver emergency preparedness information when we have everyone’s attention.

What makes #hellastorm stand out was a tenor of hyperlocal audience targeting that we were able to achieve via Nextdoor (note: Nextdoor has a social network for each San Francisco neighborhood, with more than 50K members citywide). We also received requests for more preparedness information and praise from our @sf_emergency followers, which thrilled us, considering the aforementioned.

At the heart of the matter: We’ll continue to deliver emergency preparedness information both in times of normalcy and in times of emergency. And, in closing, we want everyone to know they are more prepared than they think and to check out www. sf72.org to learn why.

Kristin Hogan is the San Francisco Department of Emergency Management’s external affairs specialist. She focuses on emergency public information dissemination and strategies to promote emergency preparedness citywide. A strong believer that we are more prepared than we think, she advocates it is not a looming disaster that inspires us to prepare but rather the peace of mind that comes from having taken a few simple steps in advance of an emergency to take care of our loved ones. She can be reached via e-mail at Kristin. hogan@sfgov.org and on Twitter @kristinlhogan.

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JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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Disaster Preparedness in San Francisco

GET INVOLVED AHEAD OF TIME Disaster Response Opportunities for Medical Professionals Rebekah Varela and Naveena Bobba, MD, MPH In the event of a disaster, having an adequate number of trained health care providers available to pitch

in can mean the difference between a successful response and a system overwhelmed by acute patient need. As a physician, there are several ways you can become involved with public health disaster preparedness and response, ranging from local to national opportunities. Choosing the level of response that is right for you depends on the amount of time you are willing and able to give to preparedness training, your ability to travel on short notice, and your own personal and family preparedness plans and obligations.

Disaster Healthcare Volunteers (DHV)

A central challenge to using medical volunteers in times of a disaster is the ability to confirm the credentials and identity of the volunteer. California has developed the Disaster Healthcare Volunteers (DHV) program to facilitate and manage the registration, credentialing, and deployment of volunteer health care professionals. DHV uses a software system to manage communication, notifications, and credentialing needs of volunteers.

There are more than forty different types of health care volunteers who can register using the DHV system. The DHV program is a single-source system operated and administered by local, regional, and state public health and emergency medical services agencies. If you are interested in helping care for San Francisco residents and visitors in a disaster, you can register for the Disaster Healthcare Volunteers (DHV) program by visiting https://www.healthcarevolunteers.ca.gov/​.

Medical Reserve Corps (MRC)

MRC units are community-based and function as a way to locally organize and use volunteers who want to donate their time and expertise to prepare for and respond to emergencies. MRC volunteers supplement existing emergency and public health resources and are, first and foremost, a local asset. Founded in 2002, the Medical Reserve Corps is housed in the Office of the Surgeon General. Currently, there are 993 community-based units and 207,783 volunteers. MRC volunteers include medical and public health professionals such as physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists.

Local plans for a Medical Reserve Corps are administered by the San Francisco Fire Department. MRC volunteers undergo training through the Neighborhood Emergency Response Program (NERT). The core skills for trained NERT volunteers, consistent with the National CERT Curriculum, include major elements of the MRC Core Competencies: triage and light treatment, personal preparedness, ICS, and terrorism awareness.

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For more information, please visit https://www.medicalreservecorps.gov/MrcUnits/UnitDetails/466.

California Medical Assistance Team/Federal Disaster Medical Assistance Team

Nationally, the federal government has the Federal Disaster Medical Assistance Team (DMAT) program as part of the National Disaster Medical System (NDMS).

During a disaster, the DMATs provide essential medical care at the disaster site as well as triage and medical care at staging and reception sites, and they prepare patients for evacuation. Six of the fifty federal DMATs are located in California. These teams are comprised of approximately 120 personnel each, with the ability to treat up to a thousand patients per day. The federal DMATs are activated solely at the discretion of the NDMS. California Medical Assistance Teams (CalMAT) are stateorganized and -funded groups of professional and paraprofessional clinical personnel, supported by a cadre of logistical and administrative staff, designed to provide medical care during a disaster or other event. Developed on the model of the federal Disaster Medical Assistance Teams, with a more rapid deployment profile, a CalMAT provides response personnel and equipment capable of rendering care under austere conditions. The CalMAT program is funded by, overseen by, and exists within the auspices of the Emergency Medical Services Authority. For more information on the Federal DMAT based out of San Francisco, please visit www.dmatca6.org. For more information on the CalMAT, please contact the State of California Emergency Medical Services Authority at CAL-MAT@emsa.ca.gov.

For more information about public health emergency preparedness, please contact San Francisco Public Health Emergency Preparedness & Response at phepr.dph@sfdph.org.

This article, originally by Rebekah Varela, health planner with the Office of Policy and Planning in the San Francisco Department of Public Health, was first published in this journal in 2008. It was updated for this issue by Naveena Bobba, MD, MPH, director, Public Health Emergency Preparedness & Response, Population Health Division at the San Francisco Department of Public Health.

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

Disaster Preparedness in San Francisco

DONATING BLOOD A Vital Aspect of Preparing for Disasters Kent Corley My grandfather was a pilot. A flight instructor in World War II, he flew many types of aircraft throughout his career. As a kid, I was fortunate to fly with him. I especially remember the preflight procedures: examining the exterior, reviewing the gauges, flipping the switches, turning the dials, and reviewing the checklists. Safety and preparation were paramount, and no flight ever began before every item on the preflight checklist was checked off.

For families, businesses, and governments, safety and preparation are paramount as well, and most have their own checklists, not for preflight but for disaster preparedness. Disaster plans are developed, written down, disseminated, and ultimately reduced to a checklist. Many of the items on the list can be readied in advance and then checked off, including food and water, flashlights and batteries, back-up generators, communications equipment, first-aid supplies, and so on.

Take a minute and consider your own disaster checklist, whether for your family, practice, hospital, or other organization. Scroll down the list and stop when you get to Donate Blood.

Take your time. Still looking? Maybe the people who created the list just forgot to include Donate Blood. Or maybe they never even thought of it at all.

Disaster and emergency preparedness plans are not usually written by physicians, but maybe they should be. If they were, just about every checklist would include Donate Blood. Few things are more vital after disaster strikes than having blood ready to transfuse. Perhaps it’s too much to expect blood donation to actually be on a list, but it should at least be part of the discussion.

From fire and flood to earthquake and tornado, some disasters strike vast areas, some engulf city blocks or neighborhoods, and others hit individual homes. In fact, a disaster can even involve just one person. When my father’s adrenal artery ruptured, it was a disaster for him and for our family. Fortunately, some civic-minded and generous stranger had put Donate Blood on the checklist—and checked it off. He or she donated blood. I know this for certain, because I was in the room when the blood bag was hung. The blood was already donated; it was on the shelf. Disaster averted, preparedness rewarded.

Blood banks are the critical link in the chain between blood donors and disaster victims. In Northern California, Blood Centers of the Pacific helps more than 100,000 patients every year, with blood donated by community volunteers who put Donate Blood on their checklist—and check it off. A nonprofit community-based organization, Blood Centers of the Pacific provides disaster-averting blood and blood components to hospitals, physicians, and patients throughout the region. It also houses the Blood Systems Research Institute, which conducts medical research to improve blood safety and patient care.

Like all blood banks, Blood Centers of the Pacific, with its staff of more than 300 physicians, phlebotomists, nurses, and others, relies on a steady flow of blood donations from anonymous blood donors. Blood banks cannot manufacture blood.

They cannot stockpile units for a rainy day. The raw material comes from humans, and it has a shelf life. Yet the need for blood never stops. Disasters don’t take holidays off, and neither do pa-

The Quiet Disaster

blood drives needed to produce sufficient units of high-demand O-negative blood.

Blood banks’ ability to collect the blood required by hospitals has been marginalized by the very hospitals that need it.

And America’s blood banks, anxious to secure hospital-system bids, make themselves a party to this disastrous cycle by accepting contracts with ever-lower prices.

The blood bank-hospital relationship will always put patient safety first, as it has for more than sixty-five years. But the economic reality is that the price hospitals pay for blood is inadequate to cover the costs of producing it, and fund-raising simply cannot close the gap. Could there come a day when patients will go untreated because of blood shortages? Physicians, hospital systems, and blood banks must begin a dialogue to avert this quiet disaster, before the FDA or another outside agency is forced to intervene. One attribute of large-scale disasters is that they expose flaws and weaknesses in systems and infrastructure.

Let’s hope this does not happen to the national blood supply.

While major disasters command the headlines, a serious but much quieter predicament is developing far from the public gaze. For more than a decade, pressure from hospital systems on the price they will pay for blood has led to blood-bank consolidation, staff reductions, and ultimately a significant change in the way blood banks collect blood. The price hospitals pay for blood is falling, while the cost of collecting, testing, and producing blood continues to rise. Hospital supply-chain management decisions have approached disaster-averting blood more like cotton swabs: just another SKU to negotiate down on price.

An apparent consequence of this price squeeze on blood banks is the lack of O-negative blood nationally. Blood banks regularly go through localized and temporary cycles of supply shortages. However, 2014 looked and felt different, as even national supplies were inadequate to make up for localized shortages. Blood banks could not effectively dig out of the O-negative deficit. There simply was not enough staff to hold the number of WWW.SFMS.ORG

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Donating Blood Continued from previous page . . .

Breathe Again !!

tients. So, unlike most other items on a disaster-preparedness checklist, Donate Blood is an activity that must be attended to regularly. Physicians, nurses, administrators, and experts in health care can make a significant impact on the blood supply simply by reminding people of the need to Donate Blood.

From 9/11 and Katrina to San Bruno and Loma Prieta, disasters often dominate the headlines. Everyone wants to do something . . . and they do. The public always responds with blood donations. They really do, with lines out the doors. Blood banks thank and salute them. But patients affected by disaster cannot wait for the generosity of these new volunteers. They need transfusions right away. Those units of blood need to be on the shelf at the hospital before disaster strikes. Regular donations of blood are essential, as we never know when disaster will strike.

Disasters ultimately are individual experiences, and many can be averted with a blood transfusion. Whether for your family of four or your organization of 4,000, whether for the small local crisis or the wide-scale natural catastrophe, donating blood can turn disaster victims into disaster survivors. So, as a health care professional, put Donate Blood on your disaster preparedness checklist—and be sure to check it off.

Kent Corley handles public relations at Blood Centers of the Pacific. To find out more about donating, visit www.bloodcenters.org.

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Disaster Preparedness in San Francisco

THE ASIANA AIRLINES ACCIDENT Mass Casualty Response and the Future of Emergency Care John Maa, MD Each year, more than 400,000 aircraft movements transport nearly 45 million passengers through San Francisco International Airport (SFO). Concur-

rently, more than 8.4 million Bay Area residents receive medical and surgical care from an array of community hospitals, community clinics, regionalized systems of care, and academic medical centers, twenty-four hours a day, 365 days a year. On July 6, 2013, the core functions of these two systems intersected after the Asiana Airline accident, with the emergency medical system (EMS) playing a critical role in transporting patients between SFO and hospital settings after this “no-notice” mass casualty incident (MCI).

That a major airliner crashed, separated into two, and caught fire with a less than 1 percent fatality rate is a tribute to advances in aviation safety and aircraft design, and to the strength and capacity of the emergency medical system that absorbed a massive surge in patient volume and complexity.

Across the nation, the American College of Surgeons (ACS) has convened Surgical Health Care Quality Forums as part of the “Inspiring Quality” initiative to enhance surgical quality and patient safety. This national effort came to San Francisco in January 2014 to highlight the key lessons learned from the Bay Area’s emergency response to the Asiana accident. Several of the on-call surgeons the day of the accident were assembled to share firsthand accounts and reflections, as well as their recommendations to strengthen the coordination and regionalization of emergency care. Fortunately, mass casualty incidents such as this are rare, and preparedness for future incidents elsewhere can be enhanced by understanding why the outcomes were so favorable, assessing what could have been done differently and better, and implementing the valuable lessons learned. The successful outcome for nearly 200 accident victims that day required efficient operations between first responders, health care professionals, emergency medical services, and paramedic transport, among many others.

The 2013 Asiana Airlines Accident

On July 6, 2013, a Boeing 777 airliner departed from Incheon International Airport in Korea. On board were 291 passengers and sixteen crew members. Nearly half of the passengers were from China; the remainder were from South Korea, the United States, Canada, India, Thailand, France, Japan, and Vietnam. According to NTSB reports, at 11:28 a.m. the plane crashed short of the threshold of Runway 28L at SFO, and the WWW.SFMS.ORG

landing gear and tail struck the seawall that projects into the bay. Both engines and the tail section separated from the aircraft. The plane slid westward and came to rest to the left of the runway, 2,400 feet from the initial point of impact. About a minute later, a dark plume of smoke was observed from the wreckage, traced to a ruptured oil tank above the right engine.

Two evacuation slides deployed on the left side of the plane and were used for evacuation. The slides on the right side deployed inside the aircraft, pinning the flight attendants seated nearby. By FAA policy, the crew on board rushed to the aid of the passengers first.

A massive combined rescue effort ensued. First-response paramedics, fire department, airport security, Coast Guard, and law enforcement teams arrived to extinguish the fire and begin the rescue and recovery. They entered the hull of the aircraft, where some passengers had to be cut free with pocketknives brought by the rescuers, as there were no sharp items on board the plane.

Finally, after all of the passengers had been evacuated, the flight attendants pinned inside the plane were freed (and were discovered to have sustained severe spinal cord injuries). One hundred eighty-one passengers were subsequently transported to twelve Bay Area hospitals spread across fifty miles.

Twelve of the Hospitals Asiana Airlines Victims Were Transported 1. San Francisco General Hospital 2. Stanford University Medical Center 3. UCSF Medical Center 4. Mills-Peninsula Hospital 5. Kaiser Permanente San Francisco 6. St. Mary’s Medical Center 7. St. Francis Medical Center 8. San Mateo Medical Center 9. Seton Medical Center in Daly City 10. St. Luke’s Medical Center 11. Sequoia Medical Center in Redwood City 12. John Muir Medical Center in Walnut Creek Source: American College of Surgeons

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They had sustained a wide range of neurosurgical, orthopedic, vascular, intra-abdominal, intrathoracic, inhalational, and burn-related injuries. Air and water evacuation routes were used in addition to standard ambulance transfer, which was impacted both by the airport closure and heavy freeway traffic. Forty-nine passengers had sustained serious injuries, 132 suffered minor injuries; the remaining 126 were uninjured. A variety of surgical procedures were performed, with a lengthy rehabilitation for both physical injuries and psychological trauma.

Lessons learned from the 2014 Inspiring Quality Summit

In trauma surgery, a key principle is the importance of the “Golden Hour”—the first hour after an accident, when prompt resuscitation, transport, and surgical intervention can be lifesaving.

Many themes that emerged from the Inspiring Quality Summit highlighted the successes, and also surprises, that came after the Asiana accident. The daily challenges of boarding and ED overcrowding must be addressed simultaneously as a massive surge of injured patients arrives in an institution. The core principle of preparedness becomes key, and effective teamwork and action are necessary to transfer patients out of the Emergency Department, ensure patient flow through available operating rooms and ICU beds, and activate call systems to ensure adequate staffing and minimize fatigue. Effective leadership is vital, particularly in the domain of crowd control and handling inquiries from the media.

The accident also brings into sharp relief the need to improve medical air access via helipads to rapidly transport critically injured patients to trauma centers, though this might be more relevant for smaller accidents rather than for a mass casualty, which rapidly overwhelms air capability.

Some of the firsthand experiences highlighted the value of social media in verifying the accuracy of field information, rapidly requesting assistance, and enhancing communication about the numbers of patients and the extent of their injuries. Also highlighted was the importance of translation and interpretation services to obtain consent and complete patient assessments, because most of the patients did not speak English. This is an area that legislation in Sacramento could strengthen. Finally, an area that warrants further study is the safety of the current singlestrap seat belts worn by coach airline passengers, compared to the three-point seat belt used in modern passenger cars (and often worn by first-class and business class passengers, who sustained less serious injuries in the Asiana accident).

Future Public Policy Efforts in Trauma and Emergency Care

Since 2010, two other transformative events, in addition to the Asiana accident response, have highlighted the importance of trauma and emergency surgery. First, the story of Arizona Congresswoman Gabrielle Gifford’s amazing recovery catalyzed a positive perception in Washington, D.C., about the heroism and courage of emergency physicians and trauma surgeons. Second, the successful outcomes from Boston hospitals to care for more than 200 patients after the April 2013 Boston Marathon bombings provided a 18

reminder to Congress and the White House of the importance of continued research in trauma and emergency care, by highlighting the importance of system preparedness and disaster drills.

Moving forward, there are three key areas for policymakers in Washington, D.C., and Sacramento to focus on in 2015. The first is to strengthen preparedness and coordination in the emergency care system, across the continuum from the site of the accident to acute in-hospital care. A 2006 Institute of Medicine report detailed a national crisis in emergency care resulting from ED overcrowding, ambulance diversion, and the boarding of admitted patients.

The successful outcome after the Asiana accident demonstrates what hospitals in a region can accomplish working collaboratively, and our legislators should seek to enhance coordination and regional preparedness. Second, adequate support of existing programs and a financial investment in future emergency and trauma care are vital to sustaining emergency departments nationwide.

The Affordable Care Act authorized $224 million to both support existing systems and to fund research into new models of trauma and emergency care. The President should now ask Congress to appropriate the $224 million to fully fund these trauma and emergency medical services programs of the Affordable Care Act and promote trauma and emergency care coordination. Third, the leadership and expertise of the ACS Committee on Trauma should be used to educate policy makers to understand the need to appropriate these ACA funds to support the continued creation of designated trauma facilities and the development of ATLS. A key opportunity is to harness the leadership and expertise of the ACS. In a 2013 Health Affairs article, ACS Past President Brent Eastman called upon Congress to act, as “full funding of these provisions is needed to stabilize statewide trauma systems that are struggling to survive.”

Since the College’s inception in 1913, the ACS and its Committee on Trauma (COT) have been leaders in advancing trauma care by designating Centers of Excellence, certifying Level One centers, disseminating the Advanced Trauma Life Support program, translating lessons from the battlefield, and developing a nationwide trauma system. Many of these programs were pioneered at San Francisco General Hospital, which has a rich legacy as an international leader in trauma research and innovation. An opportunity now exists after the experience of the Asiana accident to fully engage Bay Area trauma and emergency care experts and the San Francisco Medical Society, and make their joint efforts known more broadly to develop and implement meaningful new efforts to improve trauma care regionally, nationally, and across the globe. The United States should be proud of the first responders, emergency medical services, and health care professionals who have repeatedly risen to meet the challenges in Tucson, Boston, and San Francisco. The time has arrived to invest the time and energy to share best practices and recommendations to solve the emergency care crisis across the nation and worldwide.

John Maa, MD, FACS, is immediate past president of the Northern California Chapter of the American College of Surgeons and chair of the University of California Office of the President Tobacco Related Disease Research Program. He is on the medical staff of Marin General Hospital and is a member of the San Francisco Medical Society Board of Directors and the San Francisco Medicine editorial board.

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Disaster Preparedness in San Francisco

AMBULANCES IN SAN FRANCISCO The State of Emergency Medical Services Sebastian Wong In 1895, the City and County of San Francisco began a public ambulance service under the auspices of the Health

Department that would provide emergency medical services to residents and visitors until 1997, when the administrative responsibilities of managing the ambulances would be transferred to the San Francisco Fire Department. Some members of the San Francisco Medical Society may remember the system of emergency hospitals that served as fixed bases for the San Francisco Department of Public Health ambulances. The ambulance staff would work with the physician and the nurse at an emergency hospital, such as Park Emergency Hospital at Stanyan and Waller or Mission Emergency Hospital at the site of San Francisco General Hospital. The system of eight emergency hospitals and the ambulances were a free service provided by the City up until the passage of Proposition 13 in 1978, which reduced municipal funding through reduced property tax collection.

Today, the state of the emergency ambulance service is just as dependent on financial and political factors as it was thirty-six years ago. The merger of the DPH ambulance service with the SFFD seventeen years ago brought a much-needed level of funding to the emergency medical ambulances. What was once a fleet of sixteen ambulances prior to 1997 grew to a fleet of forty to fortyfive physical ambulance apparatus. Staffing levels were increased, and in the early 2000s response time guidelines set forth by the San Francisco EMS Agency were being met a majority of the time.

Cross-trained dual-role firefighter paramedics were also placed on twenty-nine to thirty-six of the forty-three City fire engines in an attempt to place a paramedic on scene within five minutes of an emergency request received through the 9-1-1 system. The terrorist attacks in 2001 galvanized a higher level of public funding from the federal government to provide increased capabilities in the command-and-control assets for emergency management of a significant incident in San Francisco. Unfortunately, the economic contraction in 2007–2008 created significant challenges in providing City funding for the ambulance system in the Fire Department, leading to recent headlines in the news media.

It is important to assess not just the state of the emergency ambulances in San Francisco but also the state of the Emergency Medical Services system. The system starts with the patient in need, and it is a complete partnership with all the members of the medical community in San Francisco, up to and including the receiving hospitals.

Emergency calls for service are received at the Department of Emergency Management Center at 1011 Turk Street. Call takers, using a medical priority dispatch system developed by Dr. Jeffrey Clawson, triage the calls for service and assign appropriate levels of response.

These response matrices are evaluated regularly via a medical QI process by the medical director of the EMS Agency, Dr. John Brown, and the DEM Medical Director Dr. Clement Yeh, both of whom are also attending ED physicians at the SFGH Emergency Department.

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Once the resources—i.e., fire engine, ambulance, or law enforcement units—arrive, the medical care on the scene is provided either by the City’s resources or by a private ambulance, using treatment protocols developed by the SF EMS Agency through a consensus-based process with input from the medical community and stakeholders. The care being delivered is on par with that of many metropolitan communities; however, there is a great deal of room for improvement. San Francisco has appropriate treatment protocols for pediatric care and excels in trauma care. However, when benchmarked with other metropolitan communities using the Utstein criteria in the CARES Registry out of Emory University, survival rates from out-of-hospital cardiac arrest are average or above average, not exceptional. To this end, the EMS system has identified five hospitals to receive STEMI and post-cardiac-arrestreturn-of-spontaneous-circulation patients. These hospitals are San Francisco General, Kaiser SF, Saint Mary’s, UCSF, and California Pacific Medical Center-Pacific Campus.

In spite of the gains made by the San Francisco EMS system, it is now facing a very serious challenge in how to properly and strategically advance into the future in light of our nation’s changing health care environment. The City’s emergency ambulance service responds to a call for service and, unless the patient refuses care and/or transport, the ambulance transports the patient to an emergency department or the City Sobering Center. Taking the patient to the hospital was incentivized by insurance reimbursement models in the past. High-volume users of the 9-1-1 system also pose a strain on the service and increase costs and losses to the receiving hospitals and the physicians groups staffing the emergency departments.

Case management of high-volume users by a SFFD paramedic supervisor several years ago reduced the impact of the problem, but funding to sustain his efforts ran out.

The implementation of the Patient Protection and Affordable Care Act will reduce the incentives for taking patients to hospitals via its reimbursement rules and encourage more in-home supportive care. Will—or should—the EMS system enter the arena of home health care, mobile integrated health, or community paramedics?

Should the design of the EMS System and its treatment protocols be governed by evidence-based outcomes? Today, the San Francisco EMS system is capable of handling day-to-day needs of residents and visitors in the City and County of San Francisco. It is also capable of handling significant incidents, due to the dedication and training of all its members, public and private. In the future, the state of the Emergency Medical System will depend upon the leadership of the San Francisco medical and health care community as they help guide it through the ever-changing landscape of health care.

Sebastian Wong has been a paramedic in the Bay Area and worked in the prehospital care field for over thirty-two years . He is currently the EMS Programs Director at Las Positas College in Livermore, CA. JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD

Since 1979, the Center for Sports Medicine at Dignity Health Saint Francis Memorial Hospital has been dedicated to healing the physical injuries of professional and nonprofessional athletes, performers, and active adults. With a team of multidisciplinary health professionals specializing in orthopedic surgery, primary care sports medicine, physical therapy, podiatry, physiatry, and dance medicine/Pilates, the Center provides precise, customized treatment to patients to ensure maximum recovery and get them back to enjoying healthy, active lifestyles. Dignity Health Saint Francis Memorial Hospital recently welcomed Dr. Eddie Lo to our team of experienced sports medicine professionals at the Center for Sports Medicine. Dr. Lo is an orthopedic surgeon specializing in shoulder and elbow injuries. He also performs knee and hip orthopedic procedures and shoulder replacement and handles workers’ injuries.

He received his medical degree from Columbia University and completed his orthopedic residency at the University of California, Davis. His postgraduate work includes fellowship training in shoulder surgery and sports medicine at Baylor University and Southern California Orthopedic Institute, respectively.

Dr. Lo takes pride in the notion that providing quality care entails listening to his patients and actively involving them in the caregiving process. He abides by his mentors’ philosophies: “The diagnosis comes from the patients’ stories” and “Treat your patients as you would your family.” In addition to the excellent patient care he provides, Dr. Lo has made significant contributions in his field. He has published a number of papers in peer-reviewed journals, presented his original scientific research at international conferences, and instructed surgical training sessions. A Bay Area native, Dr. Lo is fluent in Mandarin Chinese and conversational Taiwanese and has a working knowledge of Spanish. I am pleased to have Dr. Lo join our Saint Francis family as we move forward in providing comprehensive, personalized care and treatment to the San Francisco community.

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St. Mary’s

Robert Weber, MD

Dignity Health St. Mary’s Medical Center capped 2014 with events epitomizing the values of our hospital. On Nov. 4, we held a progressive dinner to engage medical professionals in the clinical programs and technologies that are the pillars of outstanding medical care at St. Mary’s. More than 200 guests toured different areas of the hospital and received information on the Sister Diane Grassilli Center for Women’s Health, St. Mary’s Spine Center, St. Mary’s Amputation Prevention/Advanced Wound Healing, Acute Rehabilitation Center, and Dignity Health Medical Group.

Also in November, St. Mary’s President and CEO, Anna Cheung, chaired the 2014 Silver SPUR Awards Luncheon held at the Moscone Center in San Francisco. The Silver SPUR Awards are given to individuals whose goals and achievements have made San Francisco and the Bay Area a better place to live, work, and play. St. Mary’s was honored to partner with SPUR, a member-supported nonprofit that promotes good planning and government for a better future for the Bay Area, to recognize this year’s award recipients.

Every day, St. Mary’s physicians, nurses, staff, and volunteers perform wonderful services for our patients, their families, and our community. But there are also the little gestures that sometimes go unrecognized yet have a real impact on the lives of those most in need. At St. Mary’s this past holiday season, these small acts of kindness came in the form of donated toys. In December, our employees came together to donate more 1,200 new, unwrapped toys to the San Francisco Firefighters Toy Program. The program provides toys to children through various community organizations, including shelters for abused women and children, inner‐city schools, children’s cancer wards, and pediatric AIDS units. For the last four years, St. Mary’s has supported this wonderful cause, and we are happy to have ended 2014 on an act of human kindness, which is the foundation of all that we do at Dignity Health. We look forward to a prosperous 2015 and wish you a happy New Year.

CPMC

Edward Eisler, MD

With the news of Ebola cases entering the U.S., CPMC took immediate action. Our first priority was to prepare and protect our frontline workers—those in registration, the emergency department, OB triage, and nursing supervisors. These employees were trained in a method we call SPCA (Screen, Protect, Contain, Alert). Screening consists of two questions: Do you have a fever? Have you been to West Africa recently or been around someone who has? If yes, the frontline worker puts on protective gear (protect) and either carefully moves the patient to an isolation area in the ED or clears the room with the patient in place (contain). The charge nurse is alerted and a quick validation process ensues before an emergency is declared (alert).

Treatment of an Ebola patient is the job of our all-volunteer Ebola Response Team (ERT), which is comprised of physicians, specialists, and nurses. Within two weeks, we had remodeled and opened a special isolation area at one of our campuses and began weekly drills for the ERT. In the first two weeks of the outbreak, we held sixteen internal forums attended by 1,000 employees. Employees were updated on our training and plans and were provided with information about the transmission of Ebola. Today, we’re involved in an ongoing cycle of learning, drilling, and refining.

Being a member of the Ebola Response Team has been a valuable learning experience for me. From the technical aspects of the protective gear to the limitations of care that can be provided in an isolated environment to the ethical considerations for patients, staff, and the general public, this is new territory for most of us. While I believe that we are prepared for the possibility that a patient infected with Ebola virus could enter our facility, the containment, control, and eradication of this disease remains a global concern.

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

Measels Update From the SFDPH Kaiser

Maria Ansari, MD

SPMF

Bill Black, MD, PhD

California is currently experiencing a measles outbreak, with at least fifty-nine confirmed cases of this airborne, highly contagious disease. San Francisco has had no reported measles cases since 2013.

Several other Bay Area counties, however, have reported cases in this outbreak.

Clinical Guidance Sometimes opportunities to improve arise from unfortunate circumstances. Such is the case with the recent Ebola epidemic in West Africa. At Kaiser Permanente, we focus a great deal of time, resources, and energy on our Emergency Management Program, and the Ebola crisis afforded us a chance to improve and refine our system even more. Kaiser Permanente was recently recognized by the Centers for Disease Control and Prevention (CDC) for its preparedness to provide inpatient care to those infected with the Ebola virus.

Since the end of August 2014, KPSF has led the regional charge in Ebola preparation and readiness. Once a suspected case of Ebola was identified in South Sacramento earlier that month, we put practices into place to ensure that all physicians and staff were properly fitted and trained with appropriate personal protective equipment (PPE). We developed ED work flows to manage a suspected or confirmed Ebola patient, briefed staff early in September, and began testing the management of an Ebola patient with drills and mock scenarios.

Additionally, by designating a few physicians and nurses in the Emergency Department as “Super Trainers,” we’ve been able to create Ebola knowledge champions whom colleagues and staff can turn to with questions and concerns. Our Ebola Response team continues to communicate regularly with outside agencies at the local, state, and federal levels to share learnings and best practices. In addition to clinical staff, every receptionist in our outpatient medical departments has been trained to ask incoming members whether they have traveled to West Africa in the past month and, if so, whether they have a fever, nausea, vomiting, diarrhea, or a cough. If the answer is yes, staff initiate a rapid-action plan to further assess and isolate the suspected case.

What Ebola has taught us for the future is that it’s imperative to have robust and intact emergency management systems in order to respond expediently. Unfortunately, the future likely holds other epidemics and disasters.

WWW.SFMS.ORG

While health care professionals have always focused on the best ways to treat patients with infectious disease, all of us certainly strengthened and tested our disaster planning mechanisms by preparing for Ebola. Since October, when Texas Health Presbyterian Hospital in Dallas treated the first case of Ebola found in the United States, physicians and health care leaders have redoubled preparations to keep staff, patients, and communities safe.

As part of the Sutter Health network, Sutter Pacific Medical Foundation (SPMF) can fortunately rely on the Sutter Health Emergency Management System, a multidisciplinary team of experts, to closely monitor the disease and share up-to-date policies, procedures, and training from federal, state, and local agencies.

Two expert leaders on our SPMF quality and infection control committees—Jordan Horowitz, MD, and Jesus Gatpolintan, MD—help ensure that Ebola preparedness remains part of daily operations in our clinics throughout San Francisco, Marin, and Sonoma counties.

The doctors make certain all staff follow CDC guidelines to screen patients on the telephone before an office visit, asking about fever, symptoms, and travel to affected West African countries. Should we identify a potential patient with Ebola during this process, staff will arrange for transport to the appropriate facility for further testing.

Should one of our care centers detect a patient with Ebola symptoms during an office visit, staff members know how to isolate the patient and protect patients in the waiting room. We conduct training and drills to keep all work flows and procedures top of mind, including the use of the right protective gear. And our efforts continue.

While most public health experts believe it’s unlikely that Ebola will become an epidemic in the United States, we can continue to improve our safety efforts by frequently communicating challenges, opportunities, and best practices with physician colleagues and government agencies. As Dr. Horowitz noted, “We are all in this together.”

Patients presenting to a medical facility with fever and a maculopapular or morbilliform rash should immediately be masked and placed in isolation or a private exam room. Patients with rash who request advice over the telephone and who are advised to present for evaluation should travel to the medical facility in a private vehicle if possible and don a surgical mask upon arrival.

Suspected measles cases should be reported immediately to the SFDPH Communicable Disease Control 24-hour line: 415-554-2830.

If calling after hours, listen to the instructions on the voicemail to page the on-call physician. Please see the “Quick Guide for Clinicians: Measles” at: http://sfcdcp.org/ measles.html.

Immunization is the most important preventive strategy for measles.

Medical providers should work with all patients to ensure up-to-date immunization status.

Patients who have been vaccinated against measles or who have a history of measles disease are considered immune.

In addition, immunity should be routinely documented for health care workers in order to prevent loss of work time if exposed. Individuals planning travel outside the USA should be up to date with immunization. Early immunization with MMR is recommended for infants aged 6-11 months before travel. For detailed recommendations, please see: wwwnc. cdc.gov/travel/yellowbook/2014/chapter3-infectious-diseases-related-to-travel/ measles-rubeola.

For the California Department of Public Health’s updates and alert flyers to post in clinical settings, see http://www. cdph.ca.gov/HealthInfo/discond/Pages/ Measles.aspx

JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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Working together, the San Francisco Medical

TOP

REASONS

To Join SFMS and CMA

PRACTICE MARKETING ASSISTANCE

Society and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining SFMS and CMA, 10 stand out.

MEMBER-ONLY ACCESS Gain full access to the SFMS website for guidelines, reports, and a variety of tools and resources to help you navigate the ever-changing health care environment.

Members also receive exclusive admission to our private networking socials and the Annual Gala.

Promote your practice through our customizable physician member page on SFMS’ website, printed Member Directory, and networking mixers.

LEGISLATIVE ADVOCACY: Ensure physicians have a voice and remain in control of medicine this year and in years to come. By speaking as a united voice, SFMS/CMA exert a powerful influence on health policy and public health issues at the local, state, and national levels.

IMPROVING COMMUNITY HEALTH Spearhead community health issues in San Francisco including Hep B Free, anti-tobacco legislation and education, formation and continuation of the Healthy San Francisco program, advocacy on reproductive and end-of-life issues, and much more.

EXPAND YOUR NETWORK Grow your professional network and referral list by networking with peers, established physicians, and health care leaders across the state at SFMS events and online communities.

PROTECTING MICRA SFMS and CMA work diligently to protect the Medical Injury Compensation Reform Act (MICRA), spearheading a successful campaign to defeat Prop 46 in the 2014 Election. Prop 46 would have dramatically altered MICRA by making it easier to file lawsuits against health care providers, increasing health care costs, reducing access to care and ultimately generating more legal fees for lawyers.

CAREER CENTER Discover new employment opportunities through the annual SFMS Career Fair. This member-only event connect SFMS physicians with recruiters from San Francisco Bay Area hospitals, medical groups, and community clinics.

STAY CONNECTED Stay up to date on vital health care issues that affect San Francisco physicians with online and print media – San Francisco Medicine journal, SFMS News e-Newsletter, and SFMS blog.

COMMITMENT TO THE PROFESSION

PRACTICE MANAGEMENT ASSISTANCE Resolve contracting, billing, and payment problems with one-on-one assistance from CMA’s team of practice management experts.

Your support of the SFMS and CMA through membership affirms your commitment to the medical profession and ensures physicians remain in control of medicine this year and in years to come.

PLEASE JOIN OR RENEW YOUR MEMBERSHIP TODAY JOIN ONLINE AT www.sfms.org/Membership/JoinNow/MembershipJoin

RENEW YOUR MEMBERSHIP ONLINE AT www.sfms.org/membership/pay-dues-online

CONTACT SFMS AT (415) 561-0850 or membership@sfms.org

HEALTH POLICY PERSPECTIVE Jack Lewin, MD

Single-Payer Dreams—and Realities If the Church of the Health Care Supreme I-ToldYou-So existed, I believe it would prophecy that America,

after trying everything else, would eventually—Tea Party or not—resort to an all-payer health care system, perhaps along the lines of Teddy Kennedy’s vision of a Medicare-for-all model, reflecting what has happened in most other countries of the developed world.

A Medicare-for-all concept would certainly be administratively simpler than our currently complex morass. The Institute of Medicine (IOM) recently estimated that $765 billion of the more than $2.7 trillion we spent on health care in the U.S. in 2013 was waste. That is, it didn’t produce more health, and it often caused unnecessary harm. A Medicare-for-all model here could, IOM thinks, save as much as $190 billion in administrative waste. This is enough to fund more than four new NIHs (National Institutes of Health)! But as the recent and unfortunate Veterans Administration embarrassment exemplifies, having government in complete control of anything other than the military is problematic for a majority of American voters. Similarly, an unchecked private sector produces child labor, unfair wages, no coffee breaks, unsafe working conditions, pollution, dangerously faulty products, and advertising on your bed pillow. A balance of power between government and the private sector is a healthy thing.

There’s a lot of emotion around the notion of a government-financed all-payer or single-payer health system. Those who hate the single-payer concept see it as unworkable, and anti-physician and anti-patient. But I predict we could be on a path to a governmentally funded system, with a key point being that over 50 percent of U.S. health care is already in this mode through the Medicare, Medicaid, VA, military, and Indian Health Service systems. In many states, one dominant insurer is a de facto private-sector single payer. Of course, insurance companies are increasingly just “back offices” that handle the administrative functions of self-insured employers who handle their own insurance risk. Employees of those companies basically have a single payer too. It seems a single-payer concept is already an American thing. Who knew?

I similarly can’t help but smile when discussing the issue with progressives—comprising, I would estimate, about onethird of the voting public—who love the single-payer concept.

The administrative simplicity is appealing. But such a system would depend on the nimbleness, commitment, and ethical responsibility of Congress and state legislatures to equitably serve the American public while funding and overseeing this kind of model. Need I say more about why this could be a flawed policy?

However, as noted, a single-payer concept would save a lot of administrative dollars that could be reallocated to other pressing national and public needs, and thus be a good thing if WWW.SFMS.ORG

well designed and implemented. But government at both the state and federal levels isn’t functioning effectively enough to warrant moving to a single payer. America is not yet ready for a de facto Medicare-for-all concept, which would need to be insulated from politics to be effective and fair (fat chance). Instead, having some genuine competition between government and a private sector in health care around quality and outcomes, efficiency, and patient satisfaction may be the best way to promote innovation and accountability on both sides. In most countries with single-payer models, there is a wraparound private sector available to people who can afford to pay for it; this reflects the frequent dissatisfaction with waiting in queues for certain high-cost services and other shortcomings in most government-dominated systems, and it also creates a two-class system based on income.

If in this country we chose to remain with a pluralistic system, the private sector would need to be a little more altruistic and less profit motivated (note that the life insurance industry has been hugely profitable and secure for decades, with an average 3 percent profit margin). Likewise, the government would need to demonstrate that it can be far less politically biased and bureaucratic if it wants to occupy a bigger space in health care with the blessings of the American people.

Bottom line: We do not have the political momentum to move toward a Medicare-for-all model in the short run. Nor is the private sector equipped to create an alternative by stepping up to a more administratively simple “managed competition” future for health care. Outside of Medicare and Medicaid, the majority of Americans remain covered by employer-based and administratively inefficient “private-sector-funded” insurance, the costs of which continue to be an increasing burden that offsets wage increases and business viability.

So, given all of that, if the publicly organized insurance exchanges created in the Affordable Care Act were to outperform private exchanges and gradually replace employer-based coverage, or if Medicare Advantage—which currently provides 30 percent of Medicare coverage through private insurers—were to grow more rapidly and expand to cover people under 65 who chose to buy in, we could, through either mechanism, be well be on our way to a uniquely American “all-payer” version of Medicare for all.

Would-be futurist Jack Lewin, MD, is president and CEO of the Cardiovascular Research Foundation, chairman of the National Coalition on Health Care, and former chief executive of the American College of Cardiology, the California Medical Association, and the State of Hawaii’s Department of Health and its public hospital systems. This article does not in any way represent the policy positions of those esteemed institutions, or of other boards on which Dr. Lewin sits.

JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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CMA HOUSE OF DELEGATES REPORT MEDICAL POLICY MAKING AT THE STATE AND BEYOND Gordon Fung, MD, PhD, and Steve Heilig, MPH

The old joke is that making laws is like making sausage: something you might—might—want to eat, but would

not like to see being done. Most physicians especially distrust the political scene, but many too recognize that medical expertise is essential to ensure “healthy” laws and regulations. And thus the annual process of developing policy on all manner of medical and public health issues for the California Medical Association and, if of national importance, the AMA. Physician delegates to the CMA are elected by each county medical association, the number based upon the number of members. We strive to have our twenty-person delegation reflect SFMS with respect to specialty, practice setting, demographics, and so forth. Any SFMS member can run for the delegation, and any member at all can draft a resolution for consideration. The SFMS delegation has a long history of being disproportionately influential; our proposals have become CMA and AMA policy on many issues, including AIDS, reproductive health, antibiotic use, drug policy, environmental health, and much more. The importance of this is that these policies guide CMA and AMA lobbying—and those are powerful presences in Sacramento and Washington. Our efforts have positively impacted countless patients and physician practices, and that’s why we persist.

The process can also be fun, believe it or not. Many new delegates have told us that they were pleasantly surprised by the camaraderie, intellectual challenges, and spirit of the few meetings we conduct prior to the CMA’s annual meeting, and at the big meeting itself. It’s a heady gathering of debate over dozens of 24

policy proposals of all types—clinical, epidemiological, scientific, economic, political, you name it. What comes out at the end is almost always something we are proud to have been part of and, if nationally relevant, it will then be taken to the AMA for further impact. The 2014 annual meeting was no exception. Some of the issues and new policies SFMS spearheaded include:

Electronic Cigarettes: CMA now supports a ban on the advertising of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids; believes that e-cigarettes should be regulated, at the state and local level, consistent with tobacco products until such time that they are approved by the FDA as smoking cessation aids; supports education of the public on the known and potential health impacts of electronic cigarettes and other nicotine delivery devices; and proposes that electronic cigarettes be taxed to generate funds, which could be used for, but not be limited to, 1) support for research into their efficacy as smoking cessation aids and their health impacts and 2) education on their known and potential health impacts.

Child Vaccination: In order to increase child vaccination rates, CMA supports the development and evaluation of educational efforts, based on scientific evidence and in collaboration with health care providers, that support parents who want to help educate and encourage reluctant parents to vaccinate their children—peer pressure perhaps being more effective than

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

health professional advice in some cases. This is, alas, timely given the recent identification of clusters of unvaccinated kids and the increase in parents opting out of vaccination for unsupportable reasons. CMA also adopted policy to discontinue allowing such personal exemptions.

Tobacco-Free Military: CMA supports the concept of a to-

bacco-free military, as proposed and supported even by military leaders, including ending tobacco sales and establishing smokefree military installations, as initiation and exposure to tobacco is high in this age-important group.

Medical Abortion Access: CMA holds that telemedicine that involves a physician for patients at medical facilities, with proper safeguards, clinical training, and patient education, can be a safe and effective route for providing medical abortion and can improve access for women who lack direct physical access to other safe abortion providers; and supports the elimination of FDA Subpart H restrictions on distribution of mifepristone.

Contraception and Teen Pregnancy: CMA supports ap-

proaches to preventing teen pregnancy that include and prioritize long-acting, reversible contraceptive (LARC) methods (e.g., the American Academy of Pediatric’s CHOICE Program).

Contraception as a Mandated Health Benefit: CMA supports state and federal efforts to require the inclusion, without copayments, of all FDA-approved contraception methods and sterilization as a mandated health benefit in all health plans.

Regulation of Commercial Genetic Testing: CMA supports the Food and Drug Administration’s regulation of commercialized genetic testing services as medical services and devices and urges that the highest standards of accuracy, risk versus benefit, patient informed consent, privacy, and marketing be applied in reviewing, approving, and regulating such testing technology and services, to minimize misleading genetic information and waste of clinical time to interpret it.

POLST Orders and Nurse Practitioners: To improve use of Physician Orders for Life-Sustaining Treatment (POLST) forms, CMA will advocate for the policy used in other states, that appropriately trained nurse practitioners/advance practice nurses and physician assistants be authorized to complete and sign POLST orders, with review by the patient’s supervising physician as appropriate, for any patients unless otherwise specified by physicians or medical staff policies. This was a “third-time’s a charm” success for us as fears about “scope of practice” issues had to be addressed.

Reimbursement for End-of-Life Counseling: CMA urges

that all public and private health care insurers be required to cover, at a reasonable reimbursement rate, counseling for end- of-life care planning as an accepted and integral part of good medical care. This is in response to the specious “death panel” charge that removed such reimbursement from the ACA; Medicare is now implementing such codes, but private insurers should also.

CMA Diversity in Leadership: CMA will consider the deWWW.SFMS.ORG

mographic diversity of its physician members when developing programs to identify future leaders, which can include but is not limited to ethnicity, national origin, religion, gender, sexual orientation, age, disability, marital status, political affiliation, and military or veteran status, in addition to mode of practice, specialty, geographic location, patient population served, and languages spoken.

Note that these are just the adopted proposals of the SFMS; there were many others, many focused on other intricacies of reimbursement, regulation, and so forth. There were also a few we opposed, many we did not have a position on, and some we supported from other county delegations, such as this:

Medication Expiration Dates: CMA will urge the FDA to discontinue the expensive and unnecessary practice of placing arbitrary expiration dates on medication labels and that these expiration dates be based on scientific data regarding drug degradation. Considering the profit motive and power of “Big Pharma,” this would likely be a long, hard battle, but perhaps in future years people will look back and note that it started here.

CMA delegates also approved, after much debate and revision, a detailed plan to streamline the HOD process and other governance requirements. SFMS delegate Roger Eng, MD, chaired the committee in charge of this difficult updating. And thus the policy-making process will continue, and the small but influential SFMS delegation will continue to have an outsize presence.

And, we should note, any SFMS member with a good idea related to medicine and public health can join in, even if only by submitting a resolution, and thus perhaps have an outsize effect on state and national health policy.

SFMS REPRESENTATIVES 2014 Gordon Fung, MD (chairman) Ameena Ahmed, MD Andrea Wagner, MD Brittany Blockman, MD David Pating, MD Elizabeth Andrews, MD Eric Tabas, MD George Fouras, MD Judy Silverman, MD Katherine Herz, MD Keith Loring, MD Lawrence Cheung, MD Mihal Emberton, MD Payal Bhandari, MD Richard Podolin, MD Rob Margolin, MD Roger Eng, MD Shoshana Ungerleider, MD Stephanie Oltmann, MD Steve Fugaro, MD Shannon Udovic-Constant, MD Brian Shaw, Medical Student Julie Wu, Medical Student Zach Wettstein, Medical Student

JANUARY/FEBRUARY 2015 SAN FRANCISCO MEDICINE

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UPCOMING EVENTS 2/12 Seminar: Managed Care Contracting in Today’s Complex Healthcare Environment February 12, 4:00 p.m. to 6:00 p.m. | Golden Gate Urology, 139 Townsend Street, San Francisco | Understanding managed care contracting in today’s everchanging health landscape is vital in the sustainability of independent provider and group practices. Join Northern California Medical Group Management Association in a 2-hour workshop focusing on health care contracting and reimbursement. Please RSVP to ben@prevailims.com. Free registration is extended to all SFMS members and their practice staff.

2/25 Seminar: Mastering the Art of Disclosing an Unexpected Outcome

February 25, 2015, 6:00 p.m.to 9:00 p.m. | Saint Francis Memorial Hospital | When an unexpected outcome occurs, a discussion explaining what happened can help prevent a negative patient response, improve patient trust, and reduce the risk of a lawsuit. Skillful physician communication and early disclosure of unintended outcomes can benefit all parties, including patients, doctors, health care systems, and insurers, without compromising meritorious defenses.

SFMS members receive complimentary registration for Medical Insurance Exchange of California (MIEC)’s effective communication seminar. The workshop is facilitated by Denise Davis, MD, UCSF associate clinical professor of medicine and a fellow of the American Academy on Communication in Healthcare. Please email rochellel@miec.com for registration information. Complimentary dinner is provided from 6:00 p.m. to 6:30 p.m.

3/5–6 Conference: Developmental Disabilities— Update for Health Professionals

March 5–6, 2015 | UCSF Laurel Heights Conference Center This annual interdisciplinary conference offers a unique, practical update for primary care and subspecialty health care professionals who care for children, youth, and adults with developmental disabilities and complex health care needs. The 2015 conference continues to cover topics across the lifespan on a broad range of developmental disabilities as well as focus on the self-advocacy movement, with presentations highlighting the twenty-fifth anniversary of the Americans with Disabilities Act. Visit http://www. ucsfcme.com/2015/MOC15001/info.html for course outline and registration information.

4/14: SFMS Lobby Day/Legislative Leadership Conference

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April 14, 2015, 9:00 p.m. to 4:00 p.m. | Sheraton Grand Sacramento | Join SFMS for the annual CMA Legislative Leadership Conference at the State Capitol. The SFMS/CMA Legislative Leadership Conference is an excellent opportunity to learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands-on experience in the practical aspects of physician advocacy. This one-day event includes education sessions on effective advocacy and lobbying techniques, briefings on legislative issues currently before Congress from CMA’s Government Relations team, and afternoon meetings at the Capitol with legislators and their staffs. More than 400 physicians, medical students, and CMA Alliance members participated in the 2014 event. Additional details for the 2015 event will be available in February 2015.

SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2015 WWW.SFMS.ORG

YOU WORK TO PROTECT YOUR PATIENTS. We work to protect you.

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That’s why the SFMS/CMA sponsors a Group Long-Term Disability program underwritten by New York Life Insurance Company: • Benefits not tied to a practice, giving you more flexibility with potential career changes • Benefit payments that are 100% TAX FREE — when you pay premiums yourself • High monthly benefits up to $10,000

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SPONSORED BY:

UNDERWRITTEN BY:

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69963, 70830 Copyright 2015 Mercer LLC. All rights reserved.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com

OR SCAN TO LEARN MORE!

Photo Courtesy of San Francisco Ballet © Erik Tomasson

Returning patients to their passions.

California Pacific Medical Center’s orthopedics program launched its Short Stay hip and knee replacement program in 2012. In 2013, CPMC was recognized by the American College of Surgeons National Surgical Quality Improvement Program as one of 37 ACS NSQIP participating hospitals that achieved meritorious outcomes for surgical care. Helping your patients return to their creative pursuits, faster. It’s another way we plus you.

cpmc.org/jointcare