June 2011

AN RANCISCO EDICINE S F M VOL.84 NO.5 June 2011

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Medicine Online

Using E-mail, Social Media, and Other Online Tools in Your Practice

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In This Issue SAN FRANCISCO MEDICINE June 2011 Volume 84, Number 5.

Medicine Online: Using E-mail, Social Media, and Other Online Tools in Your Practice FEATURE ARTICLES

10 Social Media and Medicine: Using Social Networking Sites to Learn and Communicate Jay W. Lee, MD, MPH 11 Managing Your Online Presence: What Do People Find When They Google You? Debra Phairas and Ashley Porciuncula

14 Health Care Blogging: Becoming a Resource for Health Information Online Toni Brayer, MD

15 Advice to My Patients Online: How to Advise Patients on Using the Internet for Medical Research Toni Brayer, MD 17 Doctor, Patient, Computer: The Future of Medicine in Three Parts Daniel J. Greenwood, MD

MONTHLY COLUMNS

4 Membership Matters 7 President’s Message George Fouras, MD

9 Editorial Gordon Fung, MD, PhD 26 Hospital News

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

18 Get Online to Survive: Promoting Your Practice Online Ramin Manshadi, MD, FACC, FAHA, FSCAI, FACP

19 Connecting Classes: Social Media in Medical Education Priyanka Ghosh 20 E-mail Guidelines: Advice from the Medical Insurance Exchange of California

21 Health Information Exchange: Coming Soon to a Clinical Encounter Near You Amy Berlin, MD 24 DocBook MD: A Revolutionary Communication Tool

for Physicians Laura Hale Brockway, ELS

www.sfms.org

June 2011 San Francisco Medicine 3

Membership Matters June 2011 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 84, Number 5 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

Editorial Board Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD

Erica Goode, MD, MPH

Toni Brayer, MD

Shieva Khayam-Bashi, MD

Linda Hawes Clever, MD

Arthur Lyons, MD

Peter J. Curran, MD

Stephen Walsh, MD

SFMS Officers President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Paria Rajai Board of Directors Term: Jan 2011-Dec 2013

Lily M. Tan, MD

Jennifer H. Do, MD

Shannon Udovic-

Benjamin C.K. Lau, MD

Constant, MD

Man-Kit Leung, MD

Joseph Woo, MD

Keith E. Loring, MD Terri-Diann Pickering, MD

Term: Jan 2009-Dec 2011

Marc D. Rothman, MD

Jeffrey Beane, MD

Rachel H.C. Shu, MD

Andrew F. Calman, MD Lawrence Cheung, MD

Term: Jan 2010-Dec 2012

Roger Eng, MD

Gary L. Chan, MD

Thomas H. Lee, MD

Donald C. Kitt, MD

Richard A. Podolin, MD

Cynthia A. Point, MD

Rodman S. Rogers, MD

Adam Rosenblatt, MD

CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

4 San Francisco Medicine June 2011

CMA EHR Desk Reference for Physicians Available Now! Electronic health record (EHR) adoption, implementation, and achievement meaningful use can be daunting tasks.

The CMA Physicians’ EHR Desk Reference, released this month, is comprised of information created, collected, and organized into a user-friendly format that can help guide physicians and their staff to successful EHR implementation and qualifying for thousands of dollars in federal EHR incentives.

The Desk Reference is a toolkit designed to assist physicians with the practical information required to assess, implement, and adopt an electronic solution in their practices, from understanding the federal incentive programs to selecting and implementing the right EHR system and achieving meaningful use.

This resource is available free of charge to all physicians regardless of membership status, thanks to the generous support of the Physician Foundation. To obtain your free copy in electronic format, please visit the CMA HIT Resource Center website at http://www.cmanet.org/resourcelibrary/detail?item=ehr-desk-reference.

EHR Model Contracts

We are pleased to announce a new member benefit that will assist physicians with the difficult task of negotiating an EHR contract. The EHR Model Contract is a template that may be used to identify standard EHR contract language that will provide physician protection and call out key business issues to be considered. Common “hot spots” are identified including meaningful use certifications, third-party requirements for purchase, liability, payment terms, transferability, and licensing/training/ support provisions. The Model Contract is available to all SFMS/CMA members at http://www.cmanet.org/resourcelibrary/detail/?item=model-ehrsoftware-license-and-support.

CMA Webinar Calendar CMA is offering a number of excellent webinars this year that are free to SFMS members. Register at www.cmanet.org/ calendar.

• June 15: Best Practices for Accounts Receivables | Mary Jean Sage • 12:15 p.m. to 1:15 p.m. and 6:00 p.m. to 7:00 p.m.

SFMS Webinars

The SFMS will offer the following webinars in partnership with ACCMA. Visit our website, www.sfms.org/events, for full details or to register. Contact Posi Lyon with any questions at plyon@sfms.org or (415) 561-0850 extension 260.

• June 22: Managing Your Managers (for Physicians) |12:30 p.m. to 1:45 p.m.

• July 13: CalOSHA Training for the Medical Practice |12:30 p.m. to 1:45 p.m.

SFMS On-Site Seminars

• October 14, 2011: Creating a Director of First Impressions—Customer Service, Patient Relations, and Telephone Techniques This half-day practice management seminar provides valuable training for both front and back office staff to handle patients and tasks efficiently and professionally, using superlative customer service skills. This seminar will provide your staff with the tools necessary for positive patient relations. 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast). $95 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for nonmembers. Contact Posi Lyon, plyon@sfms.org or 415-561-0850 extension 260 for more information.

• October 28, 2011: ‘MBA’ for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management.

This seminar teaches the core business www.sfms.org

elements of managing a practice, which physicians don’t receive in medical school training. 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers.

Contact Posi Lyon at plyon@sfms.org or 415-561-0850 extension 260 for more information.

A Note of Thanks to the SFMS from Blood Centers of the Pacific Thank you, SFMS and Dr. Erica Goode for including “The History of the Blood Bank” in your April issue. It couldn’t have come at a more appropriate time, as Irwin Memorial Blood Centers—now known as Blood Centers of the Pacific—is celebrating its 70th anniversary this month. The hard work, innovation, and dedication of doctors DeWitt, Burnham, John Upton, and Curtis Smith, among others, paved the way for the blood center to thrive and grow, providing much-needed blood to patients at San Francisco hospitals and beyond.

We particularly enjoyed the colorful imagery recounted in the article of bottles of plasma lying on their sides, connected to a Desi-Vac, looking like “a sow with her piglets,” and Dr. Upton working at midnight, wearing his tuxedo from the evening’s events.

The blood center has changed a lot since those first days in 1941, but one thing has remained constant— the innovation and hard work of its staff and the dedication of the many blood donors who give selflessly so that others may live.

Nora V. Hirschler, MD President & CEO Blood Centers of the Pacific

www.sfms.org

The SFMS Welcomes New Staff Members Jessica Kuo, MBA, joined SFMS in April 2011 as the Associate Executive Director for Membership Development. She has eight years of community development and program management experience working with nonprofit grassroots organizations and medical associations and has developed an understanding of the professional issues facing physicians today.

In her role with SFMS, Jessica will provide strategic oversight of the medical society’s membership, communications, and marketing initiatives. Prior to joining SFMS, Jessica was the membership manager at the California Academy of Family Physicians—a network of more than 7,000 physicians, residents, and medical students—where she facilitated solid membership growth and increased participation from traditionally inactive member segments when associations were experiencing decline during the down economy.

Jessica holds a BA from the University of California, Berkeley, and a masters in business administration from the Stanford Graduate School of Business. She is a member of the American Society of Association Executives and Young Nonprofit Professionals Network (San Francisco Bay Area).

Paria Rajai is a business professional with expertise in marketing strategy. Upon graduation from the University of California, Los Angeles, Paria worked as a financial analyst at Yahoo! for two years. She decided to pursue her passion for social change by working as a marketing and fund-raising strategist for the Carr Educational Foundation, a global education nonprofit. She will now use her experience in Web 2.0, database administration, and donor management to serve the local medical community as a membership assistant for the San Francisco Medical Society.

NEPO Encourages Health Care Providers to Learn More about HIT José Alberto Arévalo, MD, FAAFP As the current chair of the Network of Ethnic Physician Organizations (NEPO) and chair of its Health Information Technology (HIT) Committee, I am dedicated to helping our ethnic physician organizations and our solo/small-group practices realize the importance of moving forward toward electronic health records and digital technology.

NEPO would like to help by providing updated and reliable information about HIT and electronic health records (EHR) transition and by connecting you to the appropriate Regional Extension Center (REC) or Local Extension Center (LEC) to provide you with the technical assistance to get started and help you become a successful and satisfied user of electronic medical data. I encourage healthcare providers to sign up with your REC and become part of the future of health care by being a meaningful user of a certified EHR. Please contact Phoua Moua at pmoua@thecmafoundation.org or (916) 779-6636 to get more information about getting connected with your REC or LEC. June 2011 San Francisco Medicine 5

Get More Support

Luis Bonilla, M.D. Hill Physicians provider since 2010.

Uses Hill inSite, RelayHealth and Ascender for eligibility, eClaims processing, secure online communications, ePrescribing, eReferrals and preventive care reminders.

Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,600 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations.

Get more for your practice and your patients by affiliating with Hill Physicians Medical Group.

Get more information at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com

Hill Physicians’ 3,600 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

President’s Message George Fouras, MD

Recent SFMS Happenings

A

pril and May were busy for the SFMS and for me. I have met with the medical staffs of Chinese and St. Francis Hospitals. As part of our effort to stay in touch with each local hospital, several members, Mary Lou Licwinko, and I have met with new Board of Supervisors members Ms. Cohen and Mr. Weiner. However, one event turned out to be an exceptional opportunity for the SFMS. I was able to attend the “Future of Health Care Leadership Summit” at the hotel Marriott, along with several other SFMS members. Among the panel members were Dr. Warren Browner, CEO of California Pacific Medical Center; Bill Kramer, executive director of National Health Policy Pacific Business Group on Health; Mark Laret, CEO of the UCSF Medical Center; Paul Markovich, COO of Blue Shield of California; Steve McDermott, CEO of Hill Physicians Medical Group; and Chris Rauber, San Francisco Business Times health reporter. The discussion focused on health care trends, costs and how to diminish them, and ways to provide improved service. However, one of the issues that has been important to our society has been the development of universal access to care, a primary reason we have been a strong advocate for Healthy San Francisco. So I posed a threepoint question to the panel.

The first point was that when I started medical school, health care costs were roughly 11 percent of GDP; they have now risen to approximately 17 percent. Second point: It is not uncommon for the public to scream out “no socialized medicine” when the issue of universal health care arises. This even extends to members of Congress and the legislature. However, I would like to say to them, “Let me introduce you to Medicare.” Third point: Among the group of mature, industrialized nations—the United Kingdom, France, and Germany come to mind—most have managed to achieve universal health care coverage with lower health care costs and the same or better health care outcomes than the United States. So I ask: Do you foresee any form of universal health care coverage in our future?

Mark Laret of UCSF made the interesting comment that it benefits our society to have universal health care coverage, because when you use ideology to exclude certain groups (such as illegal immigrants), you continue to have a negative impact on the health care of the general population, because the excluded groups still become sick and need care.

www.sfms.org

What surprised me was the way several panel members started to qualify the point about other industrialized nations, saying that they’re cutting costs and having problems as well.

Yet none of them answered my question—which I found simultaneously amusing and telling. In my opinion, there is no perfect health care delivery system. But one of the things that has always impressed me when traveling abroad in a country such as the United Kingdom is that I could fall, I could come down within an illness, I could have a heart attack—and no matter, I would be transported somewhere to receive appropriate care without being asked to show my insurance card. And I would leave without being handed a bill.

And so the debate continues.

By the time you read this, our brand-new website should be online, or close to it. It will be highly interactive and allow members more options for enjoying the benefits of membership.

Once you’re online, I encourage you to update your profile. Add a recent photo of yourself. Many people from the public go to a website or other form of social media in order to find you. Be a part of the larger social village.

The New SFMS.org Launches in July!

We’ve been hard at work creating a new SFMS.org to better serve physicians and patients in San Francisco. The new site will be available in July and more detailed information about all the benefits and features will be available in next month’s issue of San Francisco Medicine.

• Find an SFMS doctor • Create a custom profile of you or your practice • Browse the latest health care news • Find events by type, date, and specialty • Post and read classified ads • Access the member only resource section • Read San Francisco Medicine’s current issue, archives, and more!

June 2011 San Francisco Medicine 7

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Our passion protects your practice

Editorial Gordon Fung, MD, PhD

Medical Practice and Media

T

his month’s issue is timely, in the face of health care reform that encourages the use of electronic health records (EHR) and electronic prescription use—with financial incentives and penalties if not used. Physicians and providers have jumped on the bandwagon, and according to KevinMD.com, social media’s leading physician voice, cardiologists, at 24 percent, are the leading specialty group using escripts; up to 40 percent of physicians use EHR. The federal government, insurance companies, and health maintenance organizations encourage EHR use for various reasons, but there is general consensus that it sets the stage for all providers—physicians, laboratories, hospitals, pharmacies, therapists—to communicate with each other to provide patients the best, most cost-efficient care. Some see EHR as a means of monitoring practice patterns and assessing quality indicators; others view it as a mechanism for raising physician awareness of and compliance with the latest guidelines for any particular medical condition.

So what does EHR have to do with social media and networking (SMN)? Like EHR, SMN is a product of technology.

Believe it or not, the first SMN device was the telephone. It allowed people to communicate over any distance, and eventually to teleconference—joining several people from many sites in simultaneous conversation. It required little skill beyond purchasing a phone and connection and learning how to dial the parties of interest. The next technological advance was the personal computer, allowing individuals to perform advanced calculations and store records and files electronically, and later to communicate with each other over the Internet. The Internet was the second-biggest SMN innovation. It allowed electronic communication for anyone who could learn the e-mail addresses of those they wanted to contact (as they had earlier learned their telephone numbers). E-mail allowed users to send messages to one or many people, publicly or privately. As of now, there are an estimated 1.3 billion e-mail accounts worldwide (with many people holding multiple accounts).

Another SMN development has been the use of Internet websites. Think of a website as a digital billboard that you might see if you were on the digital highway—just the way you see billboards while driving on the freeway. They provide anyone the means to make public announcements to the digital world to market a product, service, practice, or government notice or www.sfms.org

alert. According to the information-gathering site Quora, there are approximately 266,848,493 unique websites today. To help you navigate among them, search engines rate and prioritize websites according to your needs and specifications, ranking them according to any specific question you pose. There are now thirty reputable search engines, of which the best-known and largest is Google.

One other piece of the SMN puzzle is the ease of personal communication between friends and family. This was the motivation behind the networking sites Facebook, MySpace, Twitter, and LinkedIn. There are currently an estimated 350 social networks.

So how does all this affect us? Let’s take a simple scenario: Imagine you’re a physician who starts a practice in a community and wants to let everyone know that you’re new in town. The old-fashioned method would be to get membership in the county medical society and go to the places where physicians hang out. You could throw a party to announce your new practice, or take out ads in the local paper (if one even exists). Or you could design and advertise a website that describes your practice and includes pictures and stories. You could simultaneously set up a number of social networks and start spreading the word about your practice, encouraging friends to discuss your services in their own networks (going “viral”). With the website and the Internet, you could link your website to other notable sites popular among Web browsers. In a short time, your new practice could be known and hopefully busy without your even stepping into the local hospital. See how that works?

But there is another side to the story. With the Web, every interaction with a patient can be broadcast to hundreds, if not thousands, of friends and family members via social networks and sites such as Yelp or the more than fifty similar sites that actively recruit evaluations of practices and businesses. Issues of security and confidentiality, particularly regarding EHR, must be resolved so that all stakeholders are satisfied.

This month’s issue addresses some of the considerations that are unique to the interaction of SMN and medicine. Hope you enjoy it, and that it helps you navigate what some call the future of medicine.

June 2011 San Francisco Medicine 9

Medicine Online

Social Media and Medicine Using Social Networking Sites to Learn and Communicate

Jay W. Lee, MD, MPH

M

any moons ago, in the early 1990s, I remember receiving something called “an e-mail account” and thinking, “Why would I use this? I would rather just pick up the phone or walk down the hall and chat with whomever it is I need to reach.”

Well, there is probably a reason I’m not a venture capitalist, because I was dead wrong about the potential of e-mail to facilitate communication. Today, few of us can imagine a world without it. In fact, this article is the end result of a series of e-mails between the managing editor and me: Neither party picked up the phone.

Huzzah! Technology for the win!

Here we are now in the late 2000s and among many of you, my physician colleagues, social media probably engenders the same feelings I once had about e-mail: “Why would I want to do that?” I hear you and I understand. Many of us are already drowning in e-mail on top of our busy clinical schedules and family lives. The thought of adding another thing to check is anathema. Unfortunately, while we drag our collective feet on joining social media, the rest of the world—the world that our patients inhabit—is passing us by. That world is full of misinformation and hyperbole about medicine and health care. The public craves health information, and the physician voice is largely absent. As is oft repeated in organized medicine circles, if you’re not at the table, then you’re on the menu. In this case, the table refers to public opinion. We have a responsibility to be part of that public dialogue, if not for ourselves then for our patients and our communities.

What do I mean by social media?

I’ll focus our attention on two social net-

10 San Francisco Medicine June 2011

works: Facebook and Twitter.

Facebook

I knew that Facebook had reached a tipping point in medicine when the cover of the December 2010 issue of Medical Economics featured a photo of family physician Dr. Mike Sevilla and the headline, “Getting patients to ‘like’ your practice.” There are many reasons to open a Facebook account, but here are three reasons for you and your practice to use this medium:

• Content Use Facebook to get the word out about clinical issues that are pertinent to your practice. By opening a group or fan page, your practice can share content with your patients. A great way to get started is to focus this content around seasonal issues, like flu shots, and raising awareness about preventive health issues, like colon cancer screening. These updates can be sent out as frequently as daily and as infrequently as monthly. The idea is to push important information out to your patients about these issues, thereby freeing up some of the time and resources you might otherwise spend on handouts. It’s also helpful because patients can comment on your posts, giving them another way to communicate with the practice. Finally, your posts can be used to dispel commonly held myths or misunderstandings about such health issues as vaccinations.

• Marketing Facebook also helps the marketing of your practice. By being out in the public domain, you give prospective patients the opportunity to get a feel for your practice.

Having a Facebook page costs virtually nothing (unlike the costs associate with operating a website) and has broad reach.

Happy and/or loyal patients may share your page with their networks, thereby amplifying the marketing potential far beyond e-mail or a traditional website.

• Community outreach Facebook can help highlight the value that your practice brings to your community. Post about local charities or events in which you and your practice participate.

Help local schools and churches with their events by cross-posting announcements.

This type of activity helps humanize your practice.

Twitter

Do you tweet? The use of Twitter has exploded in the past year. Twitter is a social medium that limits its users to 140-character “tweets.” Each tweet reaches your followers and you can follow other “tweeps” (people who tweet). With the advent of shortened URLs, tweets can include links to articles, photos, and videos. By re-tweeting (RT), users can also share others’ tweets. A feature called “hashtags” lets users put the pound sign before a word or phrase (i.e. #FMRevolution), allowing other tweeps to search for the hashtag and follow the Twitter dialogue.

Here are a few uses of Twitter that physicians may find helpful:

• Driving business to your website/ Facebook page By adding the shortened URL to your tweets, you can drive business to your Continued on page 13 . . . www.sfms.org

Medicine Online

Managing Your Online Presence What Do People Find When They Google You?

Debra Phairas and Ashley Porciuncula

M

anaging your online presence involves more than just creating a website. It also includes monitoring your patient reviews on sites such as Yelp and other MD-rating websites, plus discovering and controlling what your own name produces when searched for on Google, Facebook, Twitter, blogs, and other online resources. It is important to proactively manage your online presence and check the Web frequently to determine patient perception of you and your practice.

Marketing a practice now includes: Assuring that information about you and your practice is accurate and up-todate.

Knowing what your patients are saying about you as physician and about your group, your staff, and your practice.

Assessing and correcting misconceptions about your practice on review sites such as Yelp, HealthGrades, or RateMDs, and responding proactively to patient complaints.

Conveying important information about your credentials and your practice, as well as helpful descriptions of medical conditions, surgeries, and procedures to your patients.

Creating efficiencies for your practice and increasing customer service by posting online patient registration forms and/or scheduling appointments.

What Do Your Patients Find When They Google You?

With the exception of the elderly (and even they are tech-savvy today), most patients don’t use the telephone book or call information when locating their own physician or finding a new one. They use Internet search engines to quickly find www.sfms.org

the telephone, address, and website of a practice. If you move your practice, be sure to update your online information immediately. When referred to several doctors, patients will often make decisions based on the information they find online. Take a professional picture of yourself with a warm, smiling face and provide a brief but comprehensive list of your credentials.

Include your philosophy of how to treat patients and make it patient-friendly. You may wish to include your hobbies or interests to make yourself more approachable. Profiling staff members is also a good idea.

Use search engine optimization (SEO) for your name to appear first on search engines. Registering with online directories will help your name, with location and a map, to be among the first results to appear.

You also don’t want the first item to pop up on a search engine to be a negative rating.

Check your online presence once a month and use any negative reviews to correct bedside manner, staff customer service, or office policies and procedures. Do not single out any staff members in meetings but discuss negative reviews with problem-solving for change. Reward positive feedback and make this a part of performance reviews.

Branding Your Image

Create a consistent brand that carries through your website and office materials.

Choose a logo, colors, and style that create a standard for your practice. It can be as simple as the doctor or group name in a font, or a professionally designed logo with an image. For example, one medical oncology and breast surgery practice has a purple iris theme that is carried out in all logos, stationery, brochures, website, and business cards, and the practice gives the patient a

vase with a purple iris after surgery.

If you are profiled in TV, radio, newspapers, or online magazines, place a clip or link on your website. This allows your patients to view this “third-party endorsement,” giving you additional credibility.

Ostensible Agency

Whether the group is an expense-share arrangement of solo practices, a combination of practices, or a sole proprietor/corporation that uses a group name, the group is creating an ostensible agency/partnership and thus has the same liability as a true, integrated group. Many physicians are unaware of this legal doctrine. This holds that if the public, patients, and other physicians think the group is a true integrated group, then the group is all liable for all members just as if they were a true group. Review CMA on-call legal documents on this subject or contact your malpractice carrier. All websites, stationery, business cards, and signs on walls and doors must be clear that this is an association of independent practices.

Social Media

You may want to join one of the popular social networking websites, such as Facebook, Twitter, LinkedIn, or others that are relevant to your business. Joining these websites gives you a face and the ability to more proactively manage your online image. Have new staff sign your office personnel policies and procedures, stating that they will not use social media sites during work hours unless they are specifically charged with updating your website or profiles. Make it clear that harassment of staff or revealing patients of the practice via social media is a breach of confidentiality Continued on page 13 . . .

June 2011 San Francisco Medicine 11

Managing Your Online Presence Continued from page 11 . . . that can be grounds for termination.

Blogs

Writing short posts about something newsworthy or educational about yourself, your specialty, or medical issues helps you stay relevant. Adding this to your website will increase your search ratings and get your message out.

Links to Other Medical Websites

Why have patients view websites that may contain inaccurate or biased medical information when you can provide them with medical sites you know are trustworthy? Put links on your website to your medical or specialty societies and to other organizations you would want patients to view.

Debra Phairas is president of Practice & Liability Consultants. Ashley Porciuncula is a website designer with more than ten years of experience. Practice & Liability Consultants, LLC, offers logo and website design services.

See sample sites at www.practiceconsultants. net.

Social Media and Medicine Continued from page 10 . . . website or Facebook page. The URL automatically becomes a hyperlink, which, when clicked, will open your website or Facebook page.

• Live tweeting Recently at two different American Academy of Family Physicians meetings and one California Academy of Family Physicians meeting, members were busy live tweeting. What this means is that folks were typing themes and messages, thereby providing a window into the meeting for people who weren’t able to attend, providing greater connectivity among physicians and greater transparency with the public.

• Learning about health policy issues In this day and age of rapid change in the health care landscape, keeping up with the latest policy issues is becoming increasingly difficult. Changes in health care (and misinformation about said changes) seemingly pop up almost as frequently as Lady Gaga’s wardrobe changes.

You can follow the pundits on both sides of the aisle, and those who are nonpartisan, to get the latest and greatest concepts in health care reform.

Clearly, the vector is moving. You want to be positioned at the table, not on the menu, right? The risks of not participating in social media now outweigh the benefits of being scared. The time is now.

See you on Facebook and Twitter!

Jay W. Lee, MD, MPH, is assistant program director and director of Health Policy at Long Beach Memorial Family Medicine Residency Program. He helped spearhead a national nonpartisan voter registration project to increase civic engagement among patients and their physicians, now called RxDemocracy. Dr. Lee also serves as new physician director for the California Academy of Family Physicians (CAFP), as a member of the CAFP Legislative Affairs Committee, and as author of its legislative blog (www.familydocs.org/blogs/jay-lee).

He is board-certified in family medicine and is an assistant clinical professor at the U.C. Irvine School of Medicine. Away from work, he is a social media hobbyist (Twitter @ familydocwonk; join the #FMRevolution!).

Why choose between national resources and local clout?

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With nearly 55,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage.

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We relentlessly defend, protect, and reward the practice of good medicine.

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www.sfms.org

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June 2011 San Francisco Medicine 13

3/23/2011 1:32:42 PM

Medicine Online

Health Care Blogging Becoming a Resource for Health Information Online

Toni Brayer, MD

I

cannot imagine life without the Internet. It’s hard to believe that the Internet and Web as we know them really didn’t take off for consumer use before 2003.

That is when search engines allowed us to find topics and information that we need to make the Internet user-friendly.

Fast-forward just eight years to 2011.

Here are a few facts (dated 2010) that show how far we have come: 1.97 billion Internet users worldwide (up 14 percent since 2009), 266.2 million Internet users in North America, 153 million blogs, 175 million people on Twitter, 600 million users of Facebook (70 percent outside the U.S.), 2 billion YouTube video views per day, 31 hours a week spent online by teens, Health information ranked as one of the most searched topics online.

Since patients are using the Internet to seek health information, it’s important that physicians guide that use and make sure the information is valid. Physicians are an integral part of the health care online industry. We are responsible for not only the patient-physician relationship but also for a complicated web of relationships with payers, pharmaceuticals, health products, and valid health information.

Online patient communities are growing at a fast clip, and patients are learning about their diseases, seeking advice, and communicating with others who have the same problems. I believe physicians should be part of this dialog and contribute to it.

That’s why I became a health blogger. I saw the Internet as a way to deliver credible, fact-based information and to espouse my point of view on health issues.

Blogs can take a variety of forms: There are blogs to sell products, promote business,

14 San Francisco Medicine June 2011

push politics, provide niche information, or just rant and rave. Physician blogs can do all of these things, but they can also be places for patients to get information that will help them live healthier lives and learn new things about medicine. That’s why I write my blog.

Millions of blogs are started each day, but only small percentages survive. It’s hard work, and building a readership takes time. Successful bloggers post new items frequently. Daily is best, because readers want a fresh look and new information when they visit. I write in the early morning or late at night and I try to write every day, but I usually succeed about five times a week. I never run out of material because my site, www.everythinghealth.net, deals with . . . well . . . everything health. There’s no end to the topics that fall under that category. The content is important and being able to write clearly is critical. A poorly written blog will not survive.

Because I’m a transparent blogger, I research my information and try to keep it nonpolitical and impersonal. But for blogs to be interesting, readers want to “connect” with the writer, so blogging is a quite different than writing scientific articles.

When I started my little blog, I never dreamed I would still be doing it four years later and would have more than a million visitors from around the world. I’ve made many friends on the blogosphere in other medical writers, and it’s a way for me to keep mentally fresh with new information.

When I read my own scientific journals, I’m constantly thinking, “Would this make a good blog?” It then takes time to break down complicated issues into readable, layman’s terms. There is so much inaccurate and incomplete information on the

Internet for patients to read, and even the news media will promote the latest study without understanding the research protocols and the power of the study to make predictions. I try to be a source of information that’s valid and understandable.

The world of social media can be fraught with peril for physicians. It’s critical that we protect patient identity and understand that the Internet is a public space that can never be erased. A University of Florida study of medical students and residents on Facebook brought up issues of nonprofessionalism, as it showed racist remarks, swearing, and drug and alcohol abuse. Anyone who has an online presence must be constantly aware that what they write can be made public. Yes, physicians are human, but we have a professional persona that must be maintained. Physicians must be aware that anything they post online may be viewed by patients—and that means anything.

Physicians have not embraced social media, usually due to lack of time. But just because we may be too busy or not interested doesn’t mean our patients aren’t using it. Younger physicians have grown up in a digital world and won’t function without computers, texting messages, smart phones, and tablets. The patients of tomorrow will expect digital connectivity with physicians’ offices and hospitals. The more we understand and embrace technology, the better we can use it for patient care and education.

Toni Brayer has been practicing internal medicine in California for more than twenty years. A former president of the SFMS, she currently serves on the editorial board for San Francisco Medicine. www.sfms.org

Medicine Online

Advice to My Patients Online How to Advise Patients on Using the Internet for Medical Research

Toni Brayer, MD

I

f you don’t think your patients are using the Internet to research health issues and even to research you, you are probably mistaken—and a little behind the times.

The number of patients who use the Internet to research health issues has increased from 90 million in 2004 to 190 million today (according to Manhattan Research). Seventy-nine percent of adults have access to the Internet and, according to the Pew Research Center and the California HealthCare Foundation, 61 percent of adults look online for health information.

What were the most common reasons those patients went to the Internet?

Sixty-six percent looked for information on a specific disease or medical problem, and 55 percent looked up a medical treatment. Fifty-two percent researched weight loss, exercise, or fitness; 47 percent researched doctors and 38 percent researched hospitals. Searches for prescription drugs, alternative treatments, and mental health issues have also been growing each year.

Most patients start their search with Google. No one is in charge of the Internet, so Google searches can go anywhere and everywhere. When I googled “hot flashes,” the page came up with eleven sponsored links to commercial supplement sites posing as medical authorities.

Advancing the search produced more ads.

Among the search results were reputable sites such as mayoclinic.org, but I had to sift through hundreds of sites that were selling something or simply offering unqualified opinions.

The beauty of the Internet is that people can access information for free, www.sfms.org

with a click of the mouse. This has made the Encyclopedia Britannica seem as oldfashioned as the Model T. Libraries, with their stacks of reference books, look like they should be museums. But the fact that patients can have access to scientific articles as well as forums where they discuss their problems with strangers who suffer from the same disease is both a blessing and a curse.

Just as we educate patients about health risks and medications, we also need to guide our “e-patients” so they can get the most out of Internet searches.

I teach my patients how to be savvy users of the Internet. For each site, I tell them to ask these questions: What is the purpose of the site? Is it to inform? Sell a product?

Raise money? Will this site protect my privacy?

The reputable cardiothoracic-surgeon-turned-media-doc Dr. Mehmet Oz was busted for his RealAge website, which sold millions of users’ personal information to pharmaceutical companies for targeted advertising. Dr. Oz’s continued promotion of this service has exposed tens of millions of health consumers to this deceptive marketing front for Big Pharma.

Online patient communities and patient forums can be found all across the Web, and they focus on a number of diseases and treatments. This collective knowledge, and the act of patients helping patients, can serve a great benefit. People support each other by talking about their shared experiences and lending emotional support for both chronic conditions and surgical recovery. A patient can find forums for insomnia, cancer, epilepsy, total joint replacement, arthritis, autism,

and just about any other condition. But some of the disease forums can lead to anxiety and confusion. The information passed around can be incorrect and filled with self-diagnosis and conflicting information. Encouraging patients to bring questions to the physician can help them sort through the facts versus the opinions that they find online.

Some patients can go overboard with their health concerns and spend so much time researching that they develop “cyberchrondria.” When I see this happening, I tell patients they have enough information and searching for more will be counterproductive. “Stop researching on the Internet; you have enough information” can be valued advice for the anxious patient who continues to search for more and more answers.

One study showed that 31 percent of physicians believe that the Internet complicates their relationship with patients and undermines their credibility.

One prestigious doctor in a professional presentation on polyarthritis (found online at CRM Healthcare) actually said, “Keeping [patients] off the Internet is an important thing to do.” This shows a profound lack of understanding of the new informed patient and implies that patients are incapable of reading and processing information.

There is no doubt that health information on the Internet is changing the relationship between doctors and patients. I love to treat informed patients, and it does not increase my workload, but it does take new communication skills to manage the time. If they bring in an article they found online, I will accept it, read it, Continued on the following page . . .

June 2011 San Francisco Medicine 15

Advice to My Patients Online Continued from page 15 . . . and discuss it. If I disagree or if it is unsubstantiated, we talk about that. Sometimes I learn something new, but usually it’s a starting point for education and understanding what the patient already knows about the problem.

When I don’t have time to educate a patient, I refer them to a website to get information. Their ability to read about a condition and learn self-help tricks or diet or exercises for musculoskeletal problems saves me time. Guiding patients to reputable, credible websites can save time in the long run and help patients manage their own conditions.

The e-patient is here to stay. Helping him or her use the Internet wisely for health conditions is the responsibility of health professionals.

Top Health Information Websites I Recommend for Patients • www.mayoclinic.org • www.healthfinder.gov • www.nih.gov • www.familydoctor.org • www.medlineplus.gov • www.kidshealth.org • www.mylifestages.org (for women) • www.merckhomeedition.com

My Favorite Health Blogs • EverythingHealth www.everythinghealth.net (my own passion) • Healthnewsreview www.healthnewsreview.org/blog (calls it like it is) • Grady Doc www.gradydoctor.com (a hospitalist in Atlanta with a heart) • Not Running a Hospital www.notrunningahospital.blogspot.com (former CEO with great insight) • Kevinmd www.kevinmd.com/blog (the master of aggregating blogs) • www.wachtersworld.com (local patient safety and quality maven) • www.getbetterhealth.com (blog aggregator and interesting reading) • Other-things-amanzi www.other-things-amanzi.blogspot.com (writings from a South African surgeon)

Go fish.

Or just enjoy a lovely seafood dinner at Fisherman's Wharf.

That's just what San Francisco and St. Francis/St. Mary’s Medical Group both offer -- lots of good choices. Whether you're looking for a new challenge in the heart of our bustling downtown or prefer a neighborhood medical center right next to Golden Gate Park, our top-rated facilities will meet and exceed your career goals. Drop us a line today and start learning about all we -- and San Francisco -- have to offer.

INTERNAL MEDICAL PHYSICIANS We are currently seeking BE/BC IM providers for outpatientfocused clinical opportunities with a growing multi-specialty clinic with a wide variety of patients.

FAMILY MEDICINE PHYSICIANS We are also seeking providers who are excited about building a new clinic, seeing a wide variety of patients and working to become the premier provider of care services in the beautiful Bay Area. These outpatient focused opportunities will allow BE/BC Family Medicine providers the ability to see full scope Family Medicine (no OB) as well as perform procedures.

In both positions, you'll benefit from an excellent call schedule with coverage from a 24-hour advice nurse who helps respond to patient questions as well as Hospitalists who are available 24/7 for admissions and inpatient management.

As a service of CHWMF, St. Francis/St. Mary’s Medical Group is affiliated with Catholic Healthcare West, one of the leading healthcare systems in the country. As a member of our team, you'll enjoy an excellent compensation and benefits package including bonus potential, a very desirable retirement plan and the opportunity to practice medicine in a cutting-edge medical community.

To learn more about our Internal Medicine positions, please send your CV to: Lori Hart, Physician Recruiter, lori.hart@chw.edu, F: (916) 853-7884. For more information on our Family Medicine opportunities, contact Colin Harris, CHWMF Physician Recruiter, at (916) 733-3415 or e-mail your CV to Colin.Harris@chw.edu.

Toni Brayer has been practicing internal medicine in California for more than twenty years. A former president of the SFMS, she currently serves on the editorial board for San Francisco Medicine. Check out her blog at www.everythinghealth.net.

16 San Francisco Medicine June 2011

www.sfms.org

Medicine Online

Doctor, Patient, Computer The Future of Medicine in Three Parts

Daniel J. Greenwood, MD

T

he age of electronic communication in medicine is upon us. At Kaiser Permanente, we have embraced the new paradigm. This technology requires behavioral adjustments, electronic etiquette, and a change in how we approach our business.

Communication with patients via e-mail is different than in the exam room. When executed thoughtfully, e-mail can increase our capacity and ability to deliver the best care possible to our patients.

Being more accessible and having less of a boundary between my patients and me can be daunting from a workload perspective. I’m learning that being more reachable via e-mail helps diffuse anxiety and stress. By receiving the message, “I’m here,” my patients are actually more at ease and, I find, less likely on the whole to overwhelm my practice on any given day. Only rarely do my patients go on at great length in e-mail regarding issues that concern them; rather, they want a quick response, a pat of reassurance. Obviously, if a situation warrants greater involvement, then e-mail is just an initial step to whatever is called for next.

I’m also finding that e-mail correspondence provides an opportunity to clarify potential miscommunication that can occur in an exam room when a patient may be under stress and not hearing everything that is said. Once they leave the office setting and are perhaps thinking more clearly, they can e-mail me and ask, “Is this what you said or did I misunderstand?” These types of follow-ups by the patient can come in the aftermath to anything from a routine laboratory test to a cancer workup.

It’s reassuring to the physician to be able to restate the plan for the patient, because it’s then more likely to be carried out. Overall, www.sfms.org

medicine is most successful when patients follow treatment plans that are clearly communicated according to a proper diagnosis, in or out of the exam room.

I find I can be more “on the patient’s side” by communicating with them via e-mail even in simple ways—ways my busy practice might otherwise preclude.

If someone has just had a baby, taking ten seconds to e-mail “congratulations” when the message comes into my inbox means a great deal to a patient. Patients who feel that we’re thinking about them even when they aren’t in the exam room have greater overall satisfaction with our physicians, and e-mail makes this possible.

It’s important to remember that, just as patients “read” what a physician is telling them through tone and body language, e-mail has its own set of unspoken dynamics. The wrong gesture or word can do much to harm the doctor/ patient relationship, and the same should be kept in mind when using any electronic communication. In our practice at Kaiser Permanente, we strive to be sensitive to these issues of e-mail etiquette and how the patient might be receiving what we’re telling them, but there is always room for improvement. Since e-mail is a relatively new realm in health care, the best ways to employ it effectively, responsibly, and professionally will continue to evolve. In some situations, e-mail should not be the tool for communicating certain types of information to a patient.

The ability to give quick feedback regarding lab results and radiological reports is another great feature of electronic communication. Waiting for results has historically been one of the most anxiety-producing realities for patients.

We now can deliver results to them via secure messaging once they have logged into Kaiser Permanente’s website, kp.org.

Each patient who registers at kp.org has access to most of their health record, the pharmacy, a messaging center, and health education information focused on prevention and well-being. The speed with which patients can access information regarding health status not only reassures them but also reduces uncertainty and delays in any necessary care.

As an integrated model of health care, Kaiser Permanente enables physicians who deliver primary care to easily access their specialist colleagues when patients require another level of care. Once the patient is referred to a specialist, their primary care provider is able to review all notes from the specialty provider and help facilitate any further treatments that might be necessary, all via electronic communication. And since Kaiser Permanente is a regional health care provider, if a patient’s condition warrants a level of care not provided at his or her own medical center, the physician can refer them to another facility for care. Again, the speed with which the arrangements can be executed and communicated to the patient helps shorten the time between diagnoses, treatment, and healing.

One challenge I have found regarding e-mail communication, and one that we are constantly working to refine, is not passing judgment on patients when they haven’t made the wisest decision about what to discuss via e-mail. Chest pain, for example, is something for which I need to pick up the phone immediately and contact the patient for more information. It’s important for Continued on page 19 . . .

June 2011 San Francisco Medicine 17

Medicine Online

Get Online to Survive Promoting Your Practice Online

Ramin Manshadi, MD, FACC, FAHA, FSCAI, FACP

W

ith implementation of the Affordable Care Act (ACA) right around the corner, along with tumultuous times currently in the practice of medicine, physicians face many challenges in their changing landscape.

In general, the practice of medicine has been dramatically affected by the state and federal budget problems. All this translates into a significant adaptation that physicians must implement in order to thrive. Physicians who can adapt quickly will succeed. These changes include taking advantage of the power of having your own website, using electronic medical records (EMR), plus implementation of social networking. As testament to this, the usage of social media grew by 50 percent in the last year, particularly among doctors aged forty-five to fifty-four, for whom usage tripled.

How does one get started? I feel the first question to ask yourself is what motivates you to create a website or involve your practice in social networking. Is it for marketing? For better patient-physician communication? Or both?

My goal in establishing my website was to better serve my patients and to keep up with the changing times. Initially, I hired a marketing company that thoroughly interviewed me to learn my strengths and established a brand based on my unique background. This information was then incorporated into the establishment of my website. Just as with building a house, the process was detailoriented and each step needed to be reworked thoroughly until it satisfied my needs. Within the website, I have not only provided information about my practice but also educational information to help

18 San Francisco Medicine June 2011

patients better understand their disease processes. I knew I had done a good job with this when a nutritionist at a local hospital told me that when searching for optimum diabetic care and education, she was able to find it on my website.

Such a website can also be used by patients to schedule appointments and to send confidential information to their providers. All of this can be interfaced with the practice’s EMR to better serve the patients. Forms can be filled out by potential patients prior to consultation, thus reducing waiting time at the office.

With accountable care organizations just around the corner and the government pushing for more transparency, the EMR is becoming a must, to the degree that a practice that hasn’t implemented EMR will, within next couple of years, risk losing bonus money from the government.

In addition, my website has links to my practice on Facebook, Twitter, LinkedIn, and in blogs—all of which I am presently in the process of developing. Let us examine these four social networks that could be used for medical social networking. Each functions in its own unique way to keep the line of communication open between provider and patients, or between provider and the general population.

Facebook is a social networking service and website launched in February 2004. Users may create personal profiles, add other users as “friends,” and exchange messages, including automatic notifications when they update their profiles. One can have a professional Facebook account in addition to a personal one.

Twitter is a website owned and operated by Twitter, Inc., which offers a social

networking and microblogging service, enabling users to send and read messages called “tweets.” Tweets are text-based posts of up to 140 characters displayed on the user’s profile page.

LinkedIn is a business-oriented social networking site. Launched in May 2003, it is mainly for professional networking. People use it to find jobs, peers, and business opportunities that are recommended by someone in one’s contact network. This is a nice way to be connected not only to medical professionals but also to professionals across many disciplines.

A blog (a blending of the term web log) is a type of website or portion of a website. Blogs are usually maintained by an individual, with regular entries of commentary, descriptions of events, or other material such as graphics or video.

An external blog is a publicly available blog where company employees, teams, or spokespersons share their views. Corporate blogs may be written primarily for consumers (business-to-consumer, or B2C) or primarily for other businesses (B2B). In the medical arena, one can use this to repeatedly remind patients to quit smoking, not to overindulge in eating, or to encourage them to take their evening walks.

Besides using these four social networks, which employ somewhat indirect approaches, a provider can send direct monthly newsletters electronically to the email addresses of all their respective patients. This is a more proactive approach to keep patients and at the same time remind them about their appointments.

Beyond marketing the practice, Continued on page 23 . . . www.sfms.org

Medicine Online

Connecting Classes Social Media in Medical Education

Priyanka Ghosh

S

he friended me last night.”

The term friended has become a widespread verb in our vocabulary because of Facebook. Facebook is just one of the myriad of social media outlets available these days. Given it’s pervasive nature, especially among teens and young adults, it’s inevitable that social media will also seep into the social practices of colleges and professional schools, including medical schools.

Social media has played an integral role in creating outlets for students to communicate with one another. The rise of social media, especially Facebook and g-mail, has contributed to creating a more cohesive, informed, and active medical school class.

Before beginning medical school, you are invited to join “Medical School X Class of Year.” Instantly, on this Facebook group, you are inundated with classmate profiles and group wall posts talking about topics ranging from accepted-students weekend to where everyone is from. Instantly, you begin to feel a sense of community with your possible future classmates and, albeit often secretly, you start assessing these people in the best way you can: by viewing their Facebook profiles. This is a helpful way to “meet” your classmates relatively early. And after meeting them in person, at an accepted-students weekend for example, Facebook also allows you to keep in touch with future classmates and further decide if you can see yourself attending four years of classes, labs, and rotations with these students. After deciding that this school is right for you, you can use this Facebook group to plan a myriad of events in the summer before medical school, from possible meet-ups to www.sfms.org

class trips. You can also use this Facebook group to pick roommates or discuss different housing choices.

Google, specifically g-mail, has also revolutionized the way in which classmates communicate with each other. Our class has a specific listserv, which has served to bring cohesion to the group.

Everyone who wants to join the Google group, or listserv, gets messages that are e-mailed to the entire group. While a listserv may sound like a commonplace thing, it really has revolutionized the way in which our class communicates about work or play, from class parties to new electives. People use this widespread listserv to advertise new electives, remind each other of assignments due, or deliver different study aids they have found or made. The listserv is also used for play, to tell the whole class which club, bar, or restaurant people are hanging out at or to advertise a pick-up soccer or basketball game.

Whenever our class wants to make a decision, our running joke is. “Let’s make a Google spread sheet about it.” While we say this in jest, Google spreadsheets truly have altered the way in which our class functions. Early on, we used them to find housing, posting “profiles,” analogous to personal ads, describing what we wanted from our living situations. Posts included our backgrounds, personal habits, housing preferences, and desired areas of the city and rent. This spreadsheet linked more than half the class to their current living situations. Now we use them to organize who will bring food to the class potluck, to decide where the class party should be, to discuss sign-ups for electives, and to coordinate large events.

The social media revolution is widespread, and as it evolves it will continue to influence many aspects of our lives. In medical school, social media and electronic communication have helped bring the class of 2014 together, and we hope it will continue to keep us together long after these four years of medical school.

And while we stay a cohesive class, we’re passing down our traditions of communication to the class of 2015. Hopefully they’ll continue to find new ways to stay cohesive through both current and new social media outlets.

Priyanka Ghosh is a first-year medical student at the University of California, San Francisco, who enjoys combining her loves of creative expression and medicine.

Doctor, Patient, Computer Continued from page 17 . . . physicians to not think the patient made a bad decision because he or she didn’t call with a potential emergency but thought to e-mail first. Patient education regarding what is suitable for e-mailing is likely to be an ongoing discussion.

Thus far, I have found e-mailing my patients to be, on balance, a positive development in my ability to provide the best care I can for them. As physicians, we’re constantly looking for new ways to help people lead healthy and balanced lives, and technology can help us do this when we use it responsibly and thoughtfully. E-mail is not the end of our communication journey, but it is a good step toward enhancing the physician/patient relationship overall.

Daniel Greenwood, MD, works in the department of internal medicine at Kaiser Permanente San Francisco.

June 2011 San Francisco Medicine 19

Medicine Online

E-mail Guidelines for Physicians Advice from the Medical Insurance Exchange of California

This article originally appeared in MIEC’s newsletter and is reprinted with permission.

E

lectronic mail (e-mail) is a popular choice for communicating with friends, relatives, and businesses; however, physicians and patients alike have been slow to embrace this medium for the exchange of health care information. Studies have been conducted to determine how frequently and under what circumstances physicians and their patients interact via e-mail, or why they do not. Numerous resources are available to interested physicians that outline the benefits and liability risks affiliated with electronic communication.

As with all aspects of a physician’s practice, MIEC encourages thorough consideration of the pros and cons of any new policy and procedure, technology, or system, before its implementation. E-mail can be a valuable time-saving communication tool, but if started in haste it may create liability problems for physicians.

Before you use e-mail in your practice, and especially before you encourage patients to communicate online with your office, consider these advantages and disadvantages.

Opinions vary

Pros: According to many articles that have been written to delineate the positive and negative features of e-mail, opinions vary greatly among physicians and their patients. Benefits discussed by physicians who advocate the use of online communication include, in part: (A) Electronic communication may enhance patient compliance with treat-

20 San Francisco Medicine June 2011

ment recommendations. In one publication, a contributing internist used as an example his patients who engage in frequent business travel, for whom it is difficult to return frequently to the physician’s practice, but who require close monitoring (e.g., Coumadin patients and prothrombin times; statin patients and liver function tests). These patients can be reminded by e-mail that follow-up lab work is needed and, once the diagnostic test has been completed and returned, the results can be e-mailed to the patients.

(B) E-mail improves efficiency when scheduling appointments and processing non-narcotic medication refills requested by established patients. One family practice physician reported that his staff can schedule an appointment in two minutes online, compared to ten to twelve minutes over the phone.

(C) E-mail allows physicians to use time more effectively when answering patients’ routine medical questions. One doctor said that he is able to answer three or four routine online messages in far less time than it takes to make three or four phone calls, and he feels less rushed.

(D) Documentation of electronic communication is better than telephonebased encounters. E-mail documentation reflects exactly what the patient asked and what the health care provider advised, unlike documentation of phone calls, which is often abbreviated, inadequate, or altogether nonexistent. Of note: Physicians and staff members who communicate with patients via e-mail should be aware that “deleted” e-mail is never truly deleted. As “electronic discovery” becomes more common in malpractice litigation, any information stored on a

hard drive or on backup tapes can be retrieved, whether or not the data has been “deleted.”

Cons: Physicians who resist using e-mail to communicate with patients give two primary reasons for their avoidance of the electronic medium: (A) Physicians question the security of protected health information transmitted via e-mail. To minimize these concerns, some physicians use secured online services such as RelayHealth, based in Emeryville, California; Medem, a company owned in part by the AMA; HealthyEmail; or MyDocOnline, Inc., an organization owned by Aventis Pharmaceuticals. Health care providers who offer online consultations charge patients a fee for the service. For example, many physicians in the Medem network charge $25 per consultation; Medem withholds a $2.50 usage fee per transaction, but only if the doctor charges the patient. (Please note: MIEC does not endorse any of the products, services, or third-party payers mentioned in this newsletter.)

(B) Health care plans do not reimburse physicians for time spent online consulting with patients. An exception is Blue Shield of California. Its network physicians may be paid $20 per e-mail consultation for minor, nonurgent matters if they use RelayHealth’s secured system.

MIEC Recommends

MIEC welcomes all technologies that enhance a medical practice. We recommend that physicians decide for themselves which technologies would benefit their practice and their patients, Continued on page 22 . . . www.sfms.org

Medicine Online

Health Information Exchange Coming Soon to a Clinical Encounter Near You

Amy Berlin, MD

T

here’s a new acronym around town.

Four unassuming letters that represent the beginnings of a transformation in how physicians, hospitals, and patients interact.

Pronounced “hizba,” HSBA stands for HealthShare Bay Area and is the newly minted name of San Francisco’s health information exchange (previously known as SFHEX). Operating under the auspices of the San Francisco Medical Society Community Service Foundation, HealthShare Bay Area is a collaboration of San Francisco physicians, hospitals, IPAs, and clinics devoted to realizing the vision of secure and efficient exchange of patient health information among care providers.

Picture being a point and a click away from an aggregate, community record for each of your patients—a view of all their medications (not just the ones you prescribe), lab results (whether from the lab in your building or the hospital across town), imaging reports, up-to-date allergy information, immunizations, and a visit history from other health care providers. Picture how much postage hospitals will save when they no longer use the U.S. mail to communicate test results to physicians, and how much money physician practices will save when their staff no longer have to spend hours filing these results in patient charts. Picture how much radiation will be avoided when patients presenting to multiple ERs have their CT results follow them wherever they go. Picture the Department of Public Health maintaining a real-time immunization registry that shows which children are due for immunizations next week—and not the ones who were missed last month. If you can picture this, then you see the future of HSBA. Working toward this future are the www.sfms.org

members of HealthShare Bay Area’s Governance Committee, who have been meeting diligently since March 2010. Over the past fifteen months, the Governance Committee has narrowed a list of potential health information exchange technology vendors from fourteen to three, drafted a business plan, and engaged a design firm to develop HSBA’s visual identity. Governance Committee members have been reaching out to local policy makers to educate them about the need for health information exchange in San Francisco. In April of this year, Supervisor David Chui wrote an op-ed in the Examiner supporting HSBA and its vision. 1 In the coming months, HSBA will launch its website, select a vendor to provide the technical architecture of the exchange, and apply to California’s state-designated entity for health information exchange, Cal eConnect 2, for grant funding. A growing area of focus for the governance committee will be education—of patients, physicians, and hospitals—about the role of health information exchange as a cornerstone of health reform.

For example, many physicians and hospitals are preparing to deploy electronic health records (EHRs) to qualify for “meaningful use.” 3 One of the requirements for Stage 1 of meaningful use is an EHR having the capability to exchange clinical information electronically. However, Stages 2 and 3 of meaningful use are expected to require EHR users to demonstrate active participation in a health information exchange. In other words, participation in HSBA will be key for San Francisco care providers who wish to qualify for meaningful use (and to continue to receive Medicare/Medicaid incentive payments) in the coming years.

Health information exchange will also play a vital role in the function of account-

able care organizations (ACOs), one of the health care delivery reform initiatives to be implemented under the Affordable Care Act, 4 and for which a proposed rule was released by Centers for Medicare and Medicaid Services (CMS) on March 31. In the Bay Area, hospitals, payers, health systems, and physicians groups have already announced plans to collaborate under this new model of care. 5 In order to provide the care coordination, information sharing, and quality metrics monitoring required by the ACO model, these disparate organizations will need a common information technology infrastructure. HealthShare Bay Area plans to provide that infrastructure.

In 1994, Dr. Paul Tang of the Palo Alto Medical Foundation conducted a study on the adequacy of health information at the point of care. 6 He found that 81 percent of the time, physicians lacked key information for clinical decision making—a finding that, nearly twenty years later, remains dishearteningly current. Federal government pressure on (coupled with resources for) health care providers to adopt health care information technology and use it to communicate with each other has created a tipping point for the transformation of health care delivery from the insulated, siloed systems represented by Dr. Tang’s research in 1994.

For San Franciscans, HealthShare Bay Area represents the beginning of this transformation to a health care system that is connected, accessible, and efficient.

Amy Berlin, MD, helps health care organizations and private practices break free from I.T. twilight zones—without compromising efficiency—drawing upon her unique background as both a practicing psychiatrist and an informatics consultant. Visit www.sfms. org/archives for a full list of references.

June 2011 San Francisco Medicine 21

Email Guidelines for Physicians Continued from page 20 . . . and make informed decisions when purchasing and using computer software, hardware, and consulting services. Consider these loss-prevention recommendations as you develop your e-mail policies: Educate yourself and your staff about the software and hardware aspects of your e-mail system. Investigate the reliability and the capacity of your Internet service provider (ISP). Ask if there is a limit on the number of messages or size of messages your individual e-mail inbox can handle. What happens if the capacity is exceeded? (Some ISPs delete older, and possibly unread, messages when a user’s in-box is full, while others reject new messages until the old ones have been read.)

Be sure you know what your ISP will do and be sure that your staff checks e-mail often enough to make sure nothing, new or old, is lost or rejected.

Decide how you will use e-mail in your office. Establish a written policy and procedure in your practice that defines how you and your staff will handle e-mail.

To avoid being overwhelmed with e-mail messages that require in-depth and/or immediate responses: (1) Communicate via e-mail only with established patients.

(2) Limit the types of communication to which you will respond (e.g., scheduling appointments, requests for nonnarcotic prescription refills, reporting normal diagnostic test results, giving medical advice for nonurgent medical concerns).

(3) Avoid using e-mail to discuss highly sensitive issues (e.g., HIV test results, STD test results, mental health information, questions of a sexual nature).

(4) Do not use e-mail to report abnormal test results. A physician should report these to patients in person or by phone, to ensure that the patient receives and understands the significance of the information, can ask questions, and is able to obtain the doctor’s follow-up advice.

(5) Determine who in your practice will respond to different categories of messages (e.g., appointments by scheduling staff; medication refills and normal test results by nursing staff after your

22 San Francisco Medicine June 2011 23 San Francisco Medicine

review and authorization, etc.).

(6) Educate patients about the limitations of your ability to make medical evaluations and diagnoses, dispense medical advice, or prescribe new medications in response to an e-mail inquiry.

(7) Print and initial a hard copy of patients’ e-mail messages and your responses; file the copy in patients’ charts.

(8) As recommended by the American Medical Association’s Guidelines for Physician-Patient Electronic Communications (available at the AMA’s website:), configure an automatic reply to patients to acknowledge receipt of their messages (e.g., “Your message has been received at the office of Dr. XX. If you have not heard from the doctor(s) within XX hours, please call, fax, or mail the office with your inquiry.” Then list the practice name, address, phone number).

(9) Establish a turnaround time for e-mail messages so patients will know when to expect your response to their inquiries. How often will the incoming mailbox be checked? If your computer’s e-mail in-box is always open (that is, your computer is always logged on to the Internet or the source of your electronic mail system), program the computer to sound a distinctive alert when new messages are received. If the computer is not continuously logged on to the e-mail system or Internet, someone must start the program frequently to check for new messages. Important: Activate the autoreply feature in your computer (or e-mail system) to inform patients that you are unavailable when you are off-call or on vacation. Advise them about how long you will be unavailable and whom to contact (and how) in your absence.

(10) Ask patients to confirm that they received a message from you and/ or your office.

Draft Written Guidelines

Once you decide how you will use e-mail in your practice, draft written guidelines to give patients who wish to correspond with your office using e-mail.

The guidelines should inform patients: (a) about the limitations of using e-mail;

(b) that messages/inquiries should be brief; (c) about the possibility that e-mail will not be received in a timely manner; (d) what to do if their e-mail inquiries are not answered in a timely manner; (e) about the possibility that improperly addressed messages or replies could be received by unauthorized persons; and (f) that reporting medical problems to the doctor by e-mail may not be a safe alternative to seeing the doctor. Inform patients that they must decide if their request can appropriately be satisfied by e-mail. They must obtain an appointment or a telephone consultation with the doctor it they believe their medical need is significant.

Ensure security of your electronic communication to protect patient confidentiality. Lawyers, medical ethicists, patient advocates, and physicians alike are concerned about the potential breach of confidentiality of information transmitted electronically. E-mail messages that are misaddressed (as the result of an omission or mistyping of one letter or digit in the recipient’s e-mail address) could reach the wrong party. Most ISPs return misaddressed messages as “undeliverable,” unless a mistyped address is the correct address for someone else.

The promptness with which misdirected messages are returned varies among ISPs. To safeguard against the possibility that a mis-sent message is read by the wrong persons (or that a properly addressed message is read by someone who has access to the recipient’s mailbox), you may encrypt your e-mail responses, which means your office and the recipient must have the same encryption software. Inquire about encryption software to preserve the confidentiality of your e-mail; if your e-mail software program does not have encryption capabilities, you may have to purchase “add-on” software.

Consider enrolling with a secured online service. (See “online services” above.)

Another safeguard against potentially misdirected e-mail is to add a disclaimer to any online responses transmitted to patients. For example, include the notice, “This message is intended only for the use www.sfms.org

of the individual(s) or entity to which it is addressed and may contain information that is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited.

If you received this communication in error, please notify the sender immediately by e-mail. Thank you for your assistance.”

Develop and implement a written patient-clinician privacy agreement for the use of e-mail.

Require patients to agree to abide by the written guidelines for the use of e-mail communication and to sign an authorization that gives you permission to communicate with them at a designated e-mail address.

Please see www.sfms.org/emailguidelines for suggested further reading and example e-mail agreements you may use in your practice.

Get Online to Survive Continued from page 18 . . . social networking can help the busy practitioner stay informed of the latest developments in his or her particular field. Medical information is changing so rapidly that in ten years, once-current information can become obsolete. Social networking can also translate into better care for the patients by opening the line of communication with the provider. It can provide information to patients on various applications that can be used on smart phones. One such application is the Diabetic Connect application provided by Alliance Health Network, Inc., on which diabetics can find a social support group. Community Health Network has an application called Pillbox that helps patients and their families keep track of their medication list on their iPhone and iTouch. There are also physician-only networks such as Sermo, OZmosis, and iMedExchange. Sermo allows doctors to share clinical information, do case studies, explore job opportunities, and even earn

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honoraria. Sermo has 112,000 physician members across sixty-eight specialties.

OZmosis is also physician-exclusive with the same characteristics as Sermo, but on a smaller scale.

The medical social network comes with its own legal issues, of which physicians should be aware. Doctors must be very careful not to post particular names of any patients. If a physician is describing a patient scenario in detail, then the information needs to be generic, so that nobody could identify the patient through reading the post. Moreover, patients have often asked to be my Facebook friends.

We should ignore these requests and draw a fine line between physician and patient relationships. Physicians should set up a Facebook account for their practice, which allows their friends to be the fans of that practice. On this page, patients can follow your updates.

In addition to this, those physicians using Sermo should be careful not to use the curbside consultation as gold standard, since accepting consultation outside of the standard of care can be thought of as malpractice. Further, anything that one writes on Twitter or in a blog is discoverable. Thus, be careful never to say anything derogatory about the hospital where you work, about other doctors, or about patients. As with anything else in life, always pause and think before posting any tweets or Facebook updates.

Because of the seriousness of the issue, the AMA has published guidelines for the use of social media. They emphasize awareness of patient privacy issues and the maintenance of personal-professional boundaries.

Just as medicine continually changes and evolves, so does our practice of it. All that I am addressing here is no longer “the future.” It is right now and should become part of any physician’s practice.

Dr. Ramin Manshadi, MD, FACC, FAHA, FSCAI, FACP, is a board-certified interventional cardiologist in private practice in Stockton. He also is an associate clinical professor at U.C. Davis in the Department of Cardiovascular Medicine. He serves as the chair of Media Relations for ACC CA. See his website at www.DrManshadi.com.

June 2011 San Francisco Medicine 23

Medicine Online

DocBookMD A Revolutionary Communication Tool for Physicians

Laura Hale Brockway, ELS

A

family physician is covering her practice’s urgent care clinic. Her first patient is a forty-five-yearold woman whose chief complaint is difficulty urinating. The patient is found to have a high fever, rapid heartbeat, and an elevated white blood cell count. The patient explains that she underwent a urological procedure three days ago, but woke this morning and could not urinate.

The family physician asks the patient for details about the surgery and asks for the name of the urologist. The patient — who has been taking hydrocodone for pain — cannot recall the name of her urologist. The family physician has her nurse access a local medical directory to find the name of the patient’s urologist. After several phone calls and two hours spent in the office waiting, the patient is sent to the emergency department to see the urologist on call.

Scenarios like this occur in physician practices every day. Communication between physicians can be inefficient and patient care can be delayed, resulting in frustration for everyone. These frustrations, however, may be short-lived. Two Austin physicians have created a tool to help solve these communication delays— DocBookMD.

DocBookMD

“We wanted to change the way physicians communicate. We wanted to make it easier, more efficient, and more secure,” says orthopedic surgeon and DocBookMD co-founder Tim Gueramy, MD. “We created a program that will allow physicians to talk to one another with new technology.”

Dr. Gueramy created DocBookMD with his wife, family physician Tracey Haas.

25 San Francisco Medicine June 2011 24 San Francisco Medicine June 2011

DocBookMD is a physicians-only iPhone app that allows physicians to: • Send HIPAA-compliant text messages and photos; • Assign an urgency setting to outgoing text messages; • Search a local pharmacy directory; and • Search a local county medical society directory (including email addresses and photos).

“DocBookMD allows you to look up another doctor at the point of care.

You can then either call the physician or send a text message with room numbers, medical record numbers, even pictures of wounds and x-rays. And all of this is sent securely and in a way that meets HIPAA requirements,” says Dr. Gueramy. The SFMS is proud to announce a partnership with DocBookMD. Beginning in August, SFMS members will be able to download the app to their smartphones. Only physicians who are members of their county medical society and also have the app will be able to access DocBookMD. The app is currently only available for Apple’s iPhone, but Android version is expected in the summer or fall of 2011.

How it Works

On-Demand messaging and multimedia collaboration: DocBookMD allows physicians to send patient information securely via text messages to other physicians. Message content can include patient information, such as diagnosis, test results, or medical history. Physicians can also add a high-resolution image of an EKG, an x-ray, lab report, or anything that can be photographed with an iPhone to the message.

Messages can then be sent using the app’s messaging priority system.

Physicians can assign each message a five-minute, fifteen-minute, or normal response time. “If the recipient does not answer the message within five minutes or if the message does not get to the doctor, you will then get a message back stating that it did not make it,” says Dr. Gueramy. “You can see and hear that the message you receive is different from any other text.” Messages sent and received are all available in the app’s messaging center for quick reference. DocBookMD currently stores messages for one year, but will soon begin storing messages for three years to meet HIT legislation compliance requirements. All messages sent using DocBookMD meet HIPAA’s requirements for encryption and the security of protected health information.

This is accomplished through technology that keeps everything encrypted on the iPhone and the DocBookMD server.

Messages are not downloaded to the phone, but are viewed from the phone.

Additionally, DocBookMD is a closed network and only physicians have access to the app. Physicians are also required to sign a HIPAA agreement before using DocBookMD. As physicians begin using DocBook, they should be aware that any evaluations, diagnoses, treatments, prescriptions, consultations, or referrals made as a result of using the app should be separately documented in the patient’s medical record.

Directories: Using the DocBookMD directory, physicians can look up other physicians in their county by first or last name or by specialty. Physicians can then www.sfms.org

contact other physicians by messaging, office phone, cell phone, or email. The pharmacy directory allows physicians to search for a local pharmacy alphabetically or find a pharmacy by zip code. Users can also create a “favorites” list of physicians or pharmacies that they contact most frequently.

How it Helps

By allowing physicians to exchange information through texting, DocBookMD prevents delays at the point of care. Austin ophthalmologist Ted Shepler, MD recently used DocBookMD to help a patient who needed her prescription urgently. The patient had no idea which pharmacy had her prescription on file. “Thanks to DocBook MD, I was able to find the pharmacy quickly for the patient,” says Dr. Shepler.

DocBookMD can also enhance patient care by facilitating more efficient communication. Austin anesthesiologist and DocBook- MD partner Aaron Ali, MD, once used the app’s directory to find a patient’s nephrologist to discuss the patient’s pre-operative lab values. The surgery was rescheduled when it was

confirmed that the patient was in acute renal failure. “The fact that I could get a hold of that physician or his office that quickly and accurately was awesome,” says Dr. Ali. “It helped out and I know 100 percent that it helped that patient that day.”

More Information

The SFMS and DocBookMD are currently working together to iron out the details of our partnership. More specific information about how to access this app will be available in the next issue of San Francisco Medicine. The app should be available to SFMS members in August 2011.

Smart Phone Apps for Physicians SFMS Members chimed in this month to tell us what their favorite smart phone applications are.

Epocrates

Drug reference

ICD9 pcp

Billing and coding

MedScape Mobile News, reference, and education

Opium

Drug equivalence calculator

Dragon Dictation Voice recognition

Convert Units Unit converter

OsiriX

Radiology images on your iPhone

FOR I p HON e , Ipa D a N D Ip OD TOUCH

A new smartphone platform designed by physicians for physicians, that provides an exclusive HIPAA-compliant professional network to help you

connect communicate and collaborate INTRODUCING

Save TI m e aN D p Re v eN T De l ayS • HIPAA-compliant • On-demand messaging • Send images of X-rays, EKGs, etc • Fast look-up of physicians and pharmacies

DocBookMD is supplied at no charge to SFMS members.

connec t c o m m u n i c a t e c o l l a b o r a t e www.sfms.org

For more details, go to

DocBookMD.com June 2011 San Francisco Medicine 25

Hospital News Kaiser

Robert Mithun, MD

The age of electronic communication between health care providers and patients is upon us. At Kaiser Permanente, we have embraced the technological revolution to help improve care across the spectrum, with outstanding results thus far. Daniel Greenwood, MD, of the Department of Medicine, says, “I’m learning over time that being more accessible to my patients diffuses a lot of anxiety and frustration. By e-mailing me when they have questions or concerns, they feel I’m always there for them, while not actually overwhelming my practice on any given day.”

E-mail correspondence provides a great opportunity to clarify communication gaps that occur among even the best providers. If a patient is able to follow up a visit by stating, in his or her own way, “I have no idea what you told me this morning,” whether regarding foot pain or a cancer screening, it is actually a huge advantage.

It is useful to reiterate the plan and reinforce the orders to be carried out. Sending a quick note to a patient who, for example, just had a baby is a positive way to enhance the existing relationship and reaffirm for the patient that their physician is interested in their health and well-being at all times, not just when they are in the exam room.

Patients also have the advantage, through e-mail communication, of being alerted when lab results and X-rays are available and then of viewing those results as soon as they log on to kp.org. The timeliness of results enables physicians to begin necessary treatments and followup in a manner most beneficial to patients who are active participants in their care, not just passive recipients.

Dr. Greenwood has also found e-mail a very successful tool in delicately approaching mental health-related issues with patients. “A simple ‘How are things going?’ is easy to send via e-mail, but you get a wealth of information in return. I’m then able to make decisions that improve the well-being of my patients who otherwise may not have communicated with me.”

26 San Francisco Medicine June 2011

UCSF

David Eisele, MD

At UCSF Medical Center, several efforts are underway to ensure that the quality of our patients’ experience matches the clinical excellence for which we are known. This commitment to improve and advance the delivery of patient care includes the implementation of an electronic health record system called Advancing Patient-centered Excellence (APeX).

This electronic health record provides a single, integrated medical record system that documents patient care across all care settings at UCSF Medical Center, UCSF Benioff Children’s Hospital, and more than 130 UCSF clinics.

APeX allows for the automatic collection and storage of patients’ health information into a comprehensive electronic medical record that can be immediately viewed by the patient’s health care team.

We know that ongoing communication with providers and access to health information are key to enhancing patients’ experiences. To meet that goal, APeX features a portal for patients to communicate securely and directly with physicians and other caregivers, request appointments, and refill prescriptions—whether at home, at work, or on the road.

Incorporating APeX into patient care settings begins the transformation of how care is delivered here. While complying with organizational best practices and protecting patient privacy, APeX will facilitate seamless interaction with patients and referring providers while improving collaboration, quality, and patient safety.

CPMC

Michael Rokeach, MD

CPMC performed the largest singlehospital kidney exchange in California. This past April, five patients received new kidneys from five healthy donors in a marathon series of operations. The procedure, which is known as “paired donation,” occurs when each patient has a willing and able donor who isn’t a compatible match but matches someone else who needs a kidney. A sophisticated computer program called Silverstone Matchgrid enabled the donors to give their kidneys, knowing their partner was going to get one in return. Matchgrid was created by David Jacobs, who came up with the idea after undergoing a kidney transplant himself at CPMC. The surgeries averaged about two hours and included five transplant surgeons, four anesthesiologists, ten operating room nurses, and a team of more than forty support staff. All ten patients are doing well.

Congratulations to Dr. Edward Eisler, who was recently reappointed for a five-year term as chair of the Department of Anesthesiology.

Dr. Eisler has served as chair of the department since 2001.

Our first informational hearing before a joint session of the San Francisco Planning and Health Commissions to discuss health care delivery, held in March, was a success.

Community health partners, employees, and patients endured long hours at City Hall to speak about their relationships with CPMC to demonstrate their support of our project. The Planning Commission is expected to hold one more informational hearing in June, and we anticipate a vote in early summer before our plan goes to the Board of Supervisors. Other issues to be discussed at these future hearings will likely include housing, workforce development, economic enhancements, and zoning.

We will keep you updated on our progress. In the mean time, visit www.rebuildcpmc.org for more information. www.sfms.org

The San Francisco Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000!

Now is the time to take a good look at the SFMS/CMA plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Endorsed by:

• You think you may be paying too much • The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance!

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51423 (6/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

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