October 2013

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

Big Data, Big Medicine Using Data to Improve Health Care Outcomes

PLUS: SFMS Election Information Career Fair November 7th PQRS Guidelines

VOL. 86 NO. 8 October 2013

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IN THIS ISSUE

SAN FRANCISCO MEDICINE October 2013 Volume 86, Number 8

Big Data, Big Medicine FEATURE ARTICLES

MONTHLY COLUMNS

12 Improving Health Outcomes: Successful Practices for

Data Use

William Strull, MD, and Andy Amster, MSPH

4

Membership Matters

6

Ask the SFMS: PQRS Guidelines

9

President’s Message Shannon Udovic-Constant, MD

14 The Promise of Big Data: The DNA of Population and

Clinical Data

Claire Brindis, PhD

16 The Health eHeart Study: Using Big Data to Fight Heart

Disease

Gregory M. Marcus, MD, MAS 18 Advancing Medical Research: The ACC National

Cardiovascular Data Registry

Ralph Brindis, MD, MPH, MACC, FSCAI

20 From Intuition to Science: Big Data Helps Run Your

Practice Efficiently

Mudit Garg and Brent Newhouse

21 Improve Care, Lower Cost: Brown & Toland Uses Data

for Better Health Outcomes

Andrew Snyder, MD, and Keith Pugliese

SPECIAL ELECTION SECTION 24 Slate of Candidates: SFMS 2013 Election 25 Candidate Biographies

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

11 Editorial

Gordon Fung, MD, PhD 15 Classified Ad

36 Medical Community News 38 In Memoriam

Nancy Thomson, MD

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Spotlights Community Health Efforts at General Meeting A wonderful time was had by all at the September SFMS General Meeting at Saint Francis Memorial Hospital. With warm enthusiasm, SFMS President Shannon Udovic-Constant, MD, welcomed local physicians to the annual event. Featured speaker San Francisco Mayor Ed Lee provided an enlightening update on the state of health care in the city. Special Guest Andy Calman, MD, SFMS PAC Chair, delivered an informative presentation about the Affordable Care Act and its impact on the medical community.

Visit the SFMS Facebook or Flickr page for photos of the Meeting.

Covered California Enrollment Launch

Beginning October 1, Californians have the opportunity to purchase health coverage through the state’s new health insurance exchange, Covered California. Twelve regional and statewide health plans are participating in Covered California, providing Californians with a diverse selection of plans from which to choose.

The new plans will go into effect on January 1, 2014, and will offer lower out-of-pocket expenses for deductibles and co-pays.

Preexisting conditions will no longer be taken into consideration, lifetime limits are eliminated, and subsidies will be available for individuals earning up to $46,000 and for families with incomes of up to $94,200.

SFMS, in partnership with the CMA and Covered California, is in the process of developing several resources to help educate physicians about the exchange and ensure that they are aware of important issues related to exchange plan contracting. There are also two educational luncheons planned in October for physicians and practice managers: October 23, 12:00 p.m. at St. Mary’s Medical Center, Morrissey Hall; October 30, 12:00 p.m. at Saint Francis Memorial Hospital, Hoffman Room

SFMS Career Fair on November 7

Calling all residents, fellows, and employers! SFMS will be hosting our fourth annual Career Fair on November 7 at the UCSF Parnassus Campus. The event runs from 5:00 p.m. until 8:00 p.m. and is complimentary to residents and fellows from the four San Francisco-based residency programs. This is an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and settings, and for employers to connect with physician job seekers.

As part of an effort to make participation accessible to all, we are offering a tiered pricing structure for employers; solo/ small group physician member practices can exhibit free of charge. For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 or visit http://www.sfms.org/Membership/StudentResidents.aspx.

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San Francisco Medicine October 2013

Physician Payment: Updates from Anthem Blue Cross, Blue Shield, Medi-Cal 11/1: Changes to Anthem Blue Cross reimbursement policies and claims software Anthem Blue Cross will be making changes to its reimbursement policies and ClaimsXten claims editing software effective November 1, 2013. Physicians may notice a difference in how certain codes and code pairs are adjudicated with the changes.

Changes include (but are not limited to) denial of 3D rendering CPT codes 76376 and 76377, assistant surgeon and cosurgeon codes eligible for payment, qualitative drug screen codes eligible for payment, and frequency edits on certain codes; denials on invalid match of diagnosis and procedure code; several changes pertaining to durable medical equipment frequency and rental; and denials of attended sleep studies billed with place of service of 21 (home).

12/1: Blue Shield Fee Schedule Changes

Blue Shield is expected to change the physician fee schedule that will take effect December 1, 2013. In a notice to physicians, the insurer said that it would be increasing payment for evaluation and management services for preventive care. Additionally, Blue Shield notes payment increases for the more commonly billed office visit codes 99204, 99205, 99213, and 99214.

Medi-Cal PCP Rate Increase

The California Department of Health Care Services (DHCS) will soon be implementing rate increases for primary care physicians who treat Medicaid patients, as authorized under the Affordable Care Act. The rate increase applies to evaluation and management codes 99201 through 99499 and vaccine administration codes 90460, 90461, and 90471-90474. In order to see the bump in pay, providers must first attest to their eligibility. According to DHCS, less than half of eligible providers had completed the brief self-attestation process as of September 24. Physicians are encouraged to complete the attestation form, which is available on the Medi-Cal website. The attestation form must be completed online (paper copies will not be accepted).

For more information on these changes and how they will impact physicians, please visit the SFMS blog at www.sfms.org.

PQRS Administrative Claims-Based Reporting Deadline Is October 15

Physicians who do not successfully participate in the Physician Quality Reporting System (PQRS) this year will be subject to PQRS payment penalties starting in 2015. PQRS is a Centers for Medicare and Medicaid Services (CMS) quality reporting program that uses a combination of incentive payments and payment adwww.sfms.org

justments to promote reporting of quality information by eligible professionals. Physicians who do not report on at least one individual measure in 2013 or elect to participate in the administrative claims reporting option will receive a 1.5 percent payment penalty in 2015. The penalty goes up to 2 percent in 2016 and beyond.

In 2013 only, CMS has made available the “administrative claims-based reporting mechanism” as an alternative method of avoiding the payment penalty in 2015. Physicians who cannot or choose not to use one of the reporting methods listed above can sign up for an exemption via the administrative claims-based reporting mechanism, before October 15, 2013. Please see page 6 for more information about how to avoid the PQRS penalty.

Governor Brown Signs CURES bill

SB 809 was signed by Governor Brown to provide funding for ongoing maintenance and staffing of the Controlled Substances and Utilization Review and Evaluation System (CURES). CURES is an online database that allows authorized users, including physicians, pharmacists, law enforcement, and regulatory boards, to access information about a patient’s controlled substance prescription history.

The bill creates a funding source for the CURES database by establishing a fee on prescribers and dispensers of controlled substances. It includes changes to CURES that will simplify and streamline the enrollment application process and that will require the development of regulations and policies to delineate how the CURES data is disclosed. It also requires the Department of Justice to create a mechanism for allowing a delegate to help check the CURES database.

Coming Soon to an Inbox Near You: Membership Renewal

2014 membership renewals are right around the corner! Make sure you continue to receive the benefits of SFMS and CMA by renewing your membership. There are three easy ways to renew your dues again this year: Mail/fax in your completed renewal form when you receive it in the mail; Renew online at www.sfms.org using your credit card; Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.

SFMS Seminar: “MBA” for Physicians and Office Managers

October 25, 2013, 9:00 a.m. to 5:00 p.m. Join nationally acclaimed practice management consultant Debra Phairas for SFMS’ popular one-day seminar designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This workshop teaches the core business elements of managing a practice that physicians don’t receive in medical school training. $225/each for SFMS/CMA members and their staff; $325/each for nonmembers. Lunch is included.

To ask questions or to register, please contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260.

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

• October 30: CMS Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties • 12:15 p.m. to 1:45 p.m.

• November 6: External Auditors and You: Medi-Cal Recovery Audit Contract Process • 12:15 p.m. to 1:15 p.m.

• November 13: Managing Difficult Employees and Reducing Conflict • 12:15 p.m. to 1:45 p.m.

• December 4: Medicare: 2014 New Rules • 12:15 p.m. to 1:15 p.m. www.sfms.org

October 2013 Volume 86, Number 8 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 John Maa, MD Chunbo Cai, MD

SFMS OFFICERS President Shannon Udovic-Constant, MD President-Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Immediate Past President Peter J. Curran, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director for Public Health and Education Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Administrative Assistant Ariel Young BOARD OF DIRECTORS Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Keith E. Loring, MD Ryan Padrez, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD John Maa, MD Edward T. Melkun, MD Justin V. Morgan, MD Kimberly L. Newell, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD CMA Trustee: Shannon Udovic-Constant, MD AMA Delegate: H. Hugh Vincent, MD AMA Alternate: Robert J. Margolin, MD

October 2013 San Francisco Medicine

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Avoiding the Medicare Quality Reporting Penalty in 2015 The Physician Quality Reporting System (PQRS) is a program developed by the Centers for Medicare and Medicaid Services (CMS) to provide a financial incentive bonus to physicians who report on best-practice quality measures for the Medicare patients they treat.

Under PQRS, Medicare will impose a 1.5% penalty in 2015 on physicians and other providers who do not successfully report at least one individual quality measure for at least one patient in 2013.

Medicare Physician Quality Reporting System Incentives and Penalties

2013 0.5% if no MoC (Maintenance of Certification) 1% if MoC (performance year for 2015 penalty) 2014 0.5%

2015 -1.5% 2016 -2%

Avoiding the Penalty in 2015 through Claims-Based Reporting For many physician practices not yet participating in PQRS, the simplest way to avoid the penalty in 2015 will be to report on one quality measure for at least one patient (preferably a few patients) on your Medicare claims. The process can be broken down into three steps: 1) selecting an appropriate measure; 2) identifying your Medicare patients to whom the measure applies; and 3) reporting the quality measure on your Medicare claims after an applicable patient encounter.

Step One: Select an Appropriate Measure

Quality measures form the basis of the PQRS program and are intended to provide information to Medicare about an aspect of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. For purposes of avoiding the penalty in 2015, physicians should select a quality measure relating to an aspect of care that they will encounter in their Medicare patient population. Review the list of individual measures that are reportable by claims posted on the SFMS website and se-

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San Francisco Medicine October 2013

lect the most frequent measure that applies to your Medicare patients.

Step Two: Learn the Details for Each Measure

After you have selected which measure to report, it is important to review the specifications for the measure with your billing staff. This will help ensure that eligible Medicare patients are appropriately identified and quality measures are accurately reported on claims. Measure specifications are developed by the Centers for Medicare and Medicaid Services (CMS) and can be accessed online at www.cms.hhs.gov/PQRS. Although the details vary across measures, each measure specification developed by CMS shares a common format and provides important information about which Medicare patients are eligible for reporting the measure based on patient demographics (age and gender), diagnosis (ICD 9 codes), and primary service(s) provided (CPT codes); the various “quality codes” that are used for reporting on Medicare claims; and the clinical rationale and information about the measure. It is important to review this information carefully, since compliance with these specifications is required for measures you report to be counted. For example, you will not get credit for reporting if the Medicare patient is outside of the age range indicated or if his or her diagnosis code is not listed on the measure specification.

Step Three: Start Reporting on Your Medicare Claims

Once you understand which Medicare patients are eligible and which “quality codes” and modifiers may be used to report the measure, you are ready to start reporting. The final step is to establish a process in your office to ensure that you consistently identify eligible patients, correctly document the correlating clinical information in the patient’s chart, and accurately report the information on your Medicare claims.

With claims-based reporting, a quality code is billed like any other procedure or E/M code (on Line 24 of the CMS 1500 form or its electronic equivalent). However, quality codes are billed at a $0.00 charge (or $0.01 if your billing system will not accept zero) and are denied by Medicare with remark code N365 indicating the code is not payable but is counted for tracking purposes. Quality codes are only counted when submitted in combination with an eligible diagnosis and service.

Quality codes submitted by themselves or along with services that have already been paid will not be counted (i.e., no retroactive claims-based reporting).

As with any other “billed” Medicare service, quality measures should be supported by documentation in the medical record, which will provide some protection in the event of an audit. Documentation should indicate in clinical terms the basis for the quality code that is reported; it is not sufficient to simply write the code in the medical record.

For official PQRS information, please visit the CMS website at www.cms.gov/pqrs.

Portions of this article were excerpted from the September-October 2013 issue of the Alameda-Contra Costa Medical Association Bulletin. www.sfms.org

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PRESIDENT’S MESSAGE Shannon Udovic-Constant, MD

Good Tech, Bad Users?

Providing medical care in this country costs too much. There are many reasons for this, such as lack of access to primary care leading to use of emergency rooms, delays in care leading to more advanced disease, duplication of services due to lack of an efficient way to share medical records—the list goes on and on.

The use of technology could allow us to provide care more efficiently. E-mailing patients has already done that in my practice—patients can attach a photo of their child’s rash, for example, allowing me to diagnose and start treatment by computer, saving a parent having to miss work and taking only five minutes versus a ten-to-fifteen-minute visit. CMA passed policy asking for insurers to pay for these “visits.” If this allows my practice to see more patients with fewer pediatricians, then we are doing our part to lower the cost curve.

How about video visits? We are just starting to look at the best use of this technology. What are the technological advances that we haven’t even thought about? Is there time in your busy workday to stop and ponder the technology that would best help your practice and your patients? In December, AliveCor’s iPhone-compatible heart monitor gained FDA approval for EKG and vital sign monitoring. David McCaman, AliveCor’s marketing director, stated, “Whereas the iPod was 1,000 songs in your pocket, now you have a clinical-quality ECG in your pocket. The big opportunities revolve around providing value to the physician in making [his or her] job easier or saving time and providing the patient with more information and ownership of their health.”

Will this do that? What about an app to test a diabetic’s blood sugar and then send the summary to the endocrinologist to adjust medication as needed? This technology is available, but there are not regulations yet to make sure that they can be trusted. The FDA has only approved a few. In early 2012, Happtique, Inc., announced that it had set up a multidisciplinary blue-ribbon panel to guide the development of a certification program to evaluate and certify mobile health care apps for professionals and patients. Should apps be certified through market-based solutions, or should they be the FDA approved? As a physician, I need to know that the technology can be trusted before I will start to use and recommend it to my patients. I want this done accurately but also quickly. FDA issued proposed rules for mobile medical applications in July 2011. We are still waiting for the final rules. Bakul Patel, the director for the Center for Devices and Radiological Health (CDRH) at the FDA, has stated that their “guidance is aimed at focusing only on devices that may prove problematic to patients.” Pretty slow so far.

Yet we need speed in certification, because our patients www.sfms.org

will use these apps with or without regulation. A recent example of patients taking things into their own hands include crowdsourcing to come up with a diagnosis. A patient can type in symptoms and a group of “MDs”—which stands for "medical detectives"—gives a diagnosis. CrowdMed tells website visitors, “As a Medical Detective, you can use your personal experience, intuition, and online research skills to help solve the world’s most difficult medical cases. You can not only win cash, prizes, and status, but also help save lives.” In my opinion this is not the way to go, as physicians prove time and time again the importance of a good physical exam in reaching the appropriate diagnosis.

Real physicians are turning to the use of checklists, information technology, and other clinical decision-support tools to aid in improved diagnosis. In addition, we need to create the ability for physicians to put their heads together, even remotely, to aid with difficult diagnoses. I have set up a threeway conference call with two pediatric subspecialists to review a case. How can we use technology to diagnose sooner and stop patients from turning to crowdsourcing?

Another way to lower the cost curve is to prevent disease or diagnose it in earlier stages. Physicians tend to take care of the patients who show up in front of them. This is due to the focus on treating illness in our payment systems. What if we were responsible for preventing illness? What technology would we want to use to aid us?

My practice has changed so much in the past twelve years. Change is hard, but the changes have been for the best, with more efficient and improved care for my patients. I look forward to helping find new ways to improve my patients’ health via the use of technology while continuing to lower the cost curve. We have to. As Nelson Mandela said, “It always seems impossible until it’s all done.”

Note: As this issue went to press the FDA released their statement on health app regulation. It is available at: http://1.usa.gov/nKd3bA.

October 2013 San Francisco Medicine

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s L S ice t c A ER isco Pra C l LO LOYn FraMnecdica Sa nd P g a EMFeatusripnitals a re

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UCSF Millberry Conference Center 500 Parnassus Ave, San Francisco

Refreshments and hors d’oeuvres provided by the SFMS For detailed event information, including a list of confirmed exhibitors, please visit http://www.sfms.org/Membership/StudentResidents.aspx 11

San Francisco Medicine October 2013

www.sfms.org

EVENT OPEN TO ALL UCSF, CPMC, ST. MARY’S, AND KAISER PERMANENTE SF RESIDENTS AND FELLOWS

EDITORIAL Gordon Fung, MD, PhD

Big Data, Big Medicine “Big Data,” according to Wikipedia, “is the term for a collection of data sets so large and complex that it becomes difficult to process using on-hand database management tools or traditional data processing applications. The challenges include capture, curation, storage, search, sharing, transfer, analysis, and visualization. The trend to larger data sets is due to the additional information derivable from analysis of a single large set of related data, as compared to separate smaller sets with the same total amount of data, allowing correlations to be found to spot business trends, determine quality of research, prevent diseases, link legal citations, combat crime, and determine real-time roadway traffic conditions”.

This definition addresses the challenges associated with big data but fails to elucidate the origin of term. Big data is a product of the digital age. Once technological advances were able to acquire bits of information such as personal identifying information, blood chemistries, DNA analysis, beat to beat blood pressures, sugar levels, exact location and activity, work productivity, trades and transactions from Wall Street to local markets there has been a effort to collect all this data, store it, analyze it, and make sense of it. As our ability to measure smaller and smaller units of activity has increased—down to nanoseconds and nanoparticles—so has the volume of data available. It has become overwhelming and there is a growing sense that we are drowning in data. We are faced with the technological challenge of analyzing volumes of data that most software programs were not developed to store or process.

The comparison of big data with the data we have been accustomed to in research is that traditionally our data collection efforts have been targeted to address very specific questions and only collect data within the parameters we need to answer our questions over a limited time period. This data is acquired and analyzed statistically and is focused within a specified duration on predefined elements with well-identified populations.

Technological advances have allowed us to open the floodgates in acquiring data in a continuous time spectrum and multiple parameters simultaneously. We not only acquire data from voluntary hospitals submitting their data on specific diseases states, like the NCDR of the ACC, we also have direct input into the collection of genetic data in the GWAS through the NIH and even streaming data from social media, the many apps that collect vital signs, images of our organs, and our blood chemistries. We also collect data on how long physicians or other providers spend with patients in clinic and hospital settings. We can see the number of hits to medical websites and tell what topics are tending and getting more attention. We can also acquire continuous telemetry monitor data when the patient is in a hospital. There are so many sources of data that it is not (yet) possible to have it all under www.sfms.org

one roof—or on one server. Our digital storage capacity now allows us to store much (but not all) of this data and so researchers or scientists can mine the data with specific questions involving specific populations over defined periods of times to answer questions about processes or diseases that were previously undetectable due to the limited data available.

Scientists, researchers—both clinical and basic—and practice analysts, have spent much of their time trying to define the role of big data in our current practice of medicine.

There is tremendous potential, as you will see from the articles submitted, from advancing medical research through the use of registries such as the NCDR as discussed by Ralph Brindis, to applications in public and global health, as discussed by Claire Brindis. The largest experiment to utilize social media and hand held devices for research with a goal of one million participants is the eHeart study being conducted at UCSF, as presented by Gregory Marcus. There are hopes to improve care, lower cost, and improve practice efficiency, as discussed

by Andrew Snyder and Keith Pugliese, Mudit Garg, and Brent Newhouse. The ultimate goal is to improve health outcomes with appropriate use of all data, as discussed by William Strull and Andy Amster.

I recently read an opinion that some clinicians are concerned about the possibility that use of big data will reward or penalize providers on patient satisfaction data, time spent per patient, and other measurements. Although this is conceivable as an outcome of big data capture and analysis, I think that the more we know the better off we are.

The more information gathered from the data the more informed we will be, and the more we know about how and where the data comes from and where it goes the more we can direct its use to improve quality of care and patient outcomes.

October 2013 San Francisco Medicine

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Big Data, Big Medicine

improving health outcomes Successful Practices for Data Use William Strull, MD, and Andy Amster, MSPH We are awash in data.

The common refrain that “we’re drowning in data, and starving for information” is as true in health care as in any other discipline. Physicians and other health care practitioners need to turn large volumes of data into information that improves health outcomes in large populations of patients. Measuring performance allows the clinician to shift in thinking from “How can I do this for the patient in front of me?” to “How can I do this for all of the patients my colleagues and I see?” This in turns helps drive improvements in the health care delivery system to ensure consistent, reliable care that improves health across the entire practice.

All health care practices—whether large or small; primary care or subspecialty; compensated by capitation; fee-forservice; or some other financial arrangement—manage large volumes of data. Patient data may exist in a traditional paper medical record; in automated clinical information systems such as lab, pharmacy, imaging, or pathology; in a full-scale electronic health record; or in some combination of the above, but one thing is certain: Patient data are voluminous and complex. Consider for a moment the challenges you face in synthesizing all of the available data for even one of your patients in a way that enables you to help that patient attain optimal health. Multiply that by the average number of patients in a primary care physician’s panel (estimated to be roughly 2,300 nationwide), and it should be readily apparent that using data to improve health outcomes doesn’t happen easily or automatically.

Fortunately, over many years of quality improvement initiatives, a number of tried-and-true practices have emerged that can help guide physicians into turning large volumes of data into information to improve health outcomes for large numbers of patients. These successful practices may be distilled into the following few guidelines.

1. Understanding the location, accuracy, and completeness of your data is critical. Whether your practice

relies on traditional paper charts or has a state-of-the-art electronic health record, you need to know where to find the necessary data to determine a patient’s eligibility for inclusion in the measurement cohort. This would include demographic data such as age and sex as well as clinical data such as diagnoses, procedures, contraindications to specific therapies, etc. Many quality improvement efforts fail because this first, important step is either ignored or it’s assumed that “somebody” can find the data.

2. Decide what to measure, and assure that the measure you select is well specified (precisely defined

with respect to numerator, denominator, inclusion and exclu12 13

San Francisco Medicine October 2013

Selecting Strongly Linked Antecedent Processes When selecting an outcome to measure and improve, select one with antecedent processes strongly linked to the outcome you are trying to improve. The reason should be obvious: Health care practitioners have direct influence over processes of care and only indirect influence over outcomes, so the actions you take to improve outcomes will likely be process-oriented. Example: “Central line-associated bloodstream infections” is an appropriate outcome measure because of the strong evidence underlying the link of specific actionable processes, including “scrub the hub,” to the desired outcome (reduced incidence of such bloodstream infections). Conversely, selecting “five-year survival for lung cancer” might not be an ideal primary care outcome, as the evidence basis for primary care processes to improve lung cancer survival is not especially strong.

sion criteria; with all diagnostic, procedural, medication- or lab-related code sets needed to compute performance results).

There are hundreds of well-specified clinical measures that have been tested, refined, and validated in multiple settings, and many of these are freely available through the Internet.

Before developing your own measures, it would be prudent to consult the websites of the National Quality Forum, the Agency for Healthcare Research and Quality, or your own specialty society for examples of well-specified, outcome-oriented quality measures that have been field-tested for validity and reliability.

And, of course, involve your staff in selecting improvement initiatives and setting targets. Their engagement and motivation are often key drivers of improvement, and their knowledge of the intricacies of your care delivery and clinical information systems will likely prove invaluable in designing and implementing measureable and meaningful improvements.

3. Understand what the “best” current outcomes are for a specific quality measure. We call the best-attained

published outcomes “benchmarks,” and these benchmarks provide guidance for setting your own short- and long-term improvement goals. Benchmarks are widely available in published literature, as well as in databases—some free, some available for purchase—from accrediting bodies such as NCQA or the Joint Commissions, or government entities such as the Centers for Medicare and Medicaid Services.

4. Don’t succumb to “analysis paralysis.” Clinical measurement has a number of inherent limitations, including measurement imprecision due to sampling when it is not practical www.sfms.org

to measure the entire “universe” of eligible patients. You should certainly recognize the importance of distinguishing “signal from noise,” but at the same time, don’t allow yourself to be handicapped by “analysis paralysis.” It doesn’t take a PhD in biostatistics to draw useful real-world conclusions about whether health outcomes are improving. The key points to keep in mind are to ensure a sufficient number of data points to justify an interpretation of improvement (or lack thereof), and a measurement period that addresses potential confounders such as seasonality. A few real-world rules of thumb: a. Measurement frequency. Measurements should be frequent enough to allow for thoughtful review of current performance, design, and implementation of interventions to improve performance and testing of the effectiveness of those interventions for sustained improvement over several subsequent measurement periods. Quarterly measurements are generally satisfactory for this purpose, although if monthly or even weekly measurements can be made cost efficiently, those would certainly be preferable. b. Address seasonal fluctuations. Many clinical measures are historically associated with seasonal fluctuations. To address this, overlapping or “rolling” measurement periods are often used to smooth these fluctuations and limit the temptation to “tamper” with inappropriate interventions that would have little or no long-term impact on health outcomes. An example of four consecutive “rolling” twelve-month measurement periods: first quarter through fourth quarter 2012, second quarter 2012 through first quarter 2013, third quarter 2012 through second quarter 2013, and fourth quarter 2012 through third quarter 2013. c. Suggested approach. In our experience, at least eight quarterly data points, reflecting two years’ worth of rolling twelve-month measurement periods, strikes a reasonable balance between the sometimes-conflicting needs for relatively frequent measurement and reporting on the one hand and sufficient opportunity to design, test, and implement strategies to improve and demonstrate sustained improvement on the other.

If the aforementioned practices are followed, then the fundamental measurement-related requisite for improving health outcomes will fall into place: Performance will be routinely measured and reported; clinical and other stakeholders will review the performance and identify gaps and opportunities for improvement; interventions will be designed, tested, refined, and implemented; performance will be remeasured and reevaluated; and if the interventions are successful, subsequent measurements will reflect sustained improvement.

A final but very important successful practice is to ensure transparency, which is absolutely critical to the improvement of health outcomes. Physicians should welcome the sharing of clinical outcomes. It is comparatively rare that suboptimal performance is a “provider problem.” Much more often, system deficiencies are the primary cause of suboptimal performance. By sharing performance results and opportunities and working together to design and implement process improvements at a system level, health outcomes are almost invariably improved, often dramatically, and in a relatively short time. Indeed, the most transparent and successful practices share measurement and improvement efforts widely, including with the clinic’s patient www.sfms.org

population, because patients, after all, carry the ultimate burden (or experience the ultimate relief) of the outcomes to which our care delivery contributes.

Across Kaiser Permanente, sophisticated electronic medical records and other electronic systems have enabled data measurement and performance improvement across all six “aims for improvement” identified by the Institute of Medicine in its 2001 Crossing the Quality Chasm report:

Safe: Measurements of SRAE (serious reportable adverse

events), including health care-acquired infections, verification events, retained foreign objects, and many others, have resulted in operational improvements in all these arenas. Timeliness of diagnoses is measured in many clinical areas, and systems to identify test abnormalities in need of follow-up or medication monitoring gaps have been implemented to help ensure timely diagnoses.

Effective: Effectiveness metrics such as Healthcare Effectiveness Data and Information Set measures have led to improvements in medication management, including adherence, which in turn have improved outcomes in key clinical areas such as hypertension, diabetes, hyperlipidemia, and osteoporosis.

Patient-centered: Surveys of hospital patients shortly after

discharge and of outpatients following clinic visits have allowed Kaiser Permanente to benchmark member satisfaction across medical centers—both within and outside Kaiser Permanente— and to target opportunities to enhance patients’ experience and satisfaction with their health care.

Timely: Measurements of access to primary and specialty care, and satisfaction with that access, have led to improvements in access to all types of care across Kaiser Permanente.

Efficient: Measurement of efficiency across all clinical areas has led to safer, more efficient processes that enhance the affordability of health care.

Equitable: Metrics that focus on disparities across race/ethnicity/socioeconomic variables have spawned initiatives to reduce or eliminate those disparities with enhanced outreach and provision of care for particular populations It all boils down to the excellent advice Dr. Atul Gawande provides in his 2007 book, Better: Count something. Regardless of what one ultimately does in medicine—or outside medicine, for that matter—one should be a scientist in this world. In the simplest terms, this means one should count something. . . . It doesn’t really matter what you count. You don’t need a research grant. The only requirement is that what you count should be interesting to you. . . . If you count something interesting, you will learn something interesting.

William Strull, MD, is medical director of Quality and Patient Safety for the Permanente Federation. Andy Amster, MSPH, is director of the Center for Healthcare Analytics at Kaiser Permanente. Amy Compton-Philips, MD, associate executive director of the Permanente Federation, and Jed Weissberg, MD, senior vice president, Kaiser Foundation Health Plan and Hospitals, also contributed to this article.

October 2013 San Francisco Medicine

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Big Data, Big Medicine

The promise of big data The DNA of Population and Clinical Data Claire Brindis, PhD The Chinese word for change is comprised of two symbols: opportunity and danger. The confluence of

the availability of a plethora of data, the technological capacity to gather and analyze individual- and population-based data, as well as the potential for linking population to clinical data, all present a unique opportunity to improve population health. Furthermore, there is increasingly compelling motivation to use information to make more targeted policy and resource allocation decisions, thus clearly shaping the way that we approach population health in the twenty-first century.

To circumvent potential “dangers,” an appropriate system of checks and balances will be required. First and foremost, educated, engaged consumers actively mobilized at both the individual and system levels are needed to help assure the appropriate use of data for their own, as well as their community’s needs. For example, the importance of ensuring that active informed consent is given for use of lab samples needs to be prioritized if we are to avoid a repeat of the Henrietta Lacks case. Secondly, incorporating a system to guard against inappropriate use and release of personal health information needs to be built into our system of care.

Similar to the promise of being able to improve the quality of reporting and better provision of care through the availability of electronic health records (EHRs), there is great promise and raised expectations for improving population health.

This includes the increasing ability to use technological breakthroughs that capture, link, store, and expeditiously analyze diverse data systems, including the layering of individual and community-level health, economic, social, and policy indicators. In addition, EHRs hold great promise for the avoidance of duplication of services, as well as more careful monitoring of patient and community health indicators.

For example, population-level data (e.g., schoolattendance data) layered with environmental air quality reports, along with medical diagnoses and hospitalizations for acute asthma episodes, may help document hot spots for chronic health conditions such as childhood asthma. To truly make progress in reducing the incidence of childhood asthma, strategies are needed both at the community level (e.g., schools built in proximity to freeways that worsen air quality), as well as at the individual level. To assure improvements in chronic disease management, technology can help create an effective bridge to improve health outcomes. For example, 14 15

San Francisco Medicine October 2013

companies are developing sensors that can be synched with a user’s cell phone to provide data that can help patients and providers monitor medication use and identify triggers for asthma. Such sensors can be attached to asthma inhalers and used for patient monitoring. This system is also being tested for use at the community level to improve public health (see http://www.rwjf.org/en/blogs/new-public health/2012/08/ asthmapolis_public.html). Thus, data made available through consumer-driven apps holds great promise for creating more tailored educational, counseling, and monitoring solutions that impact individual behavior but also provide epidemiological data on the patterns noted across large and diverse populations at risk of similar health conditions.

Within population health, an important tool has been the development of geographic information systems (GIS).

GIS not only enables the capture, storage, and analysis of data but can display such information geographically (see viz. healthmetricsandevaluation.org for examples). These tools have been used effectively in the fields of infectious disease and environmental epidemiology but have not been used as extensively to effectively link disparate health-related variables from both clinical and community health data.

GIS could not only graphically show concentrated areas of chronic health conditions but could also help us learn from areas that have successfully implemented potential solutions, particularly for reducing disease morbidity and mortality.

Data can serve as important tactics for policy and program development and implementation.

One such case is shown in San Francisco’s Health Improvement Partnerships (SFHIP) (http://www.sfhip.org/) data, which have been combined from a variety of resources to create a community profile of those clients who are most expensive to the health care system. Specifically, San Francisco General Hospital trauma registry has merged data on lab values for blood alcohol level with clinical notes, census data on community characteristics, and California state data capturing where alcohol sales outlets are geographically located (and how many legal violations they have been cited for) to identify the concentration of patients with alcohol and related health, social, and housing problems. In turn, different networks of the public health, social services, and health care delivery systems have been brought together to deploy, community-wide, evidence-based interventions ranging from local controls on alcohol sales to linking clients to a variety of services and more effective monitoring. Simultaneous targeting of population-based, environmentally and individually focused solutions is needed if this and similar problems are to be truly ameliorated. www.sfms.org

tors—will be needed to improve inter-and inner-operability The Accountable Care Act (ACA) provides a new opporand analyses of available data sets across different population tunity to reduce the long-standing chasm between population and clinical health care systems of care. health and medical care through the incorporation of big data.

We will also need to continue to actively engage and inFrom the perspective of population health, the ACA’s requirecrease the capacity of stakeholders in the use of such data. For ments to go “upstream” in eliminating health disparities and policy makers, data will point to future investments to elimithe environmental and lifestyle antecedents to chronic health nate health disparities. For providers and consumers, data conditions, including obesity, diabetes, cancer, and heart disholds promise of contributing to quality health care and outease, offers new horizons to improve the overall health of the comes, as well as patient-centered, shared decision making. public. It also requires a more comprehensive need for careful For informed communities, the availability of linked clinical monitoring and interdigitation of population and clinical data. and population-based data holds promise for a renewed call In this regard, population-level and family-centered health for change. care can play an integral role in more effective health and disease management.

Claire Brindis, PhD, is the Caldwell B. Esselstyn Chair in For example, the ACA prioritizes the elimination of perHealth Policy and the director of the Philip R. Lee Institute for verse financial incentives through reducing unnecessary Health Policy Studies at the University of California, San Francosts, improved quality of care, and avoidance of duplication cisco. of care. This is reflected in the increasing need to reduce unnecessary rehospitalizations that occur as a result of inappropriate “hand-offs” between health systems and the broader community. This requires the incorporation of “wraparound care,” often delivered through a system of family and community support services. If this vision is to be truly fulfilled, Classified Ad it will be particularly important to meet the challenge of increasing inter- and intra-operability of data across health care Medical Practice for Sale. Weight Loss & Aesthetics. Coland community systems of care to assure that patients, and in lects ~$900,000 annually. Highly desirable Central Coast turn populations, are receiving the appropriate levels of care. location. 100% Financing Available (OAC). 800-416-2055.

Furthermore, Accountable Care Organizations, which will http://TransitionConsultants.com. increasingly be responsible for diverse panels of clients, will also require linking to support services—many of which traditionally may not have been considered integral to health— such as stable housing, quality of physical environments, and availability of wholesome food, that contribute to health and well-being. Other ACA built-in requirements, specifically the provision of clinical preventive health services withINC. out co-payments and deductibles, also need data systems that help assure system accountability, A REGISTRY & PLACEMENT FIRM as well as population-level data that helps capture the impact of such screening services.

Several challenges will need to be resolved if we are to continue to make substantial improveNurse Practitioners ~ Physician Assistants ments in the nation’s health and benefit from actionable intelligence that big data potentially affords. While population health and health care delivery is the most information-intensive and dependent industry, thus far only a small percentage have effectively leveraged the data assets captured in available IT infrastructures.

This potential may worsen before it improves, as clinical and population-level data are linked.

The bottom line is to be able to convert Locum Tenens ~ Permanent Placement available data sets into the accurate and timely intelligence necessary to drive improved quality V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 outcomes, safer care, and reductions in cost— FAX : 8 0 5 - 6 4 1 - 9 1 4 3 whether it be at the patient bedside or at the community level. Regulatory, technical, private, tzweig@tracyzweig.com and public political and financial investments— w w w. t r a c y z w e i g . c o m a shared responsibility among multiple sec-

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October 2013 San Francisco Medicine

15

Big Data, Big Medicine

The Health eHEART STUDY Using Big Data to Fight Heart Disease Gregory M. Marcus, MD, MAS Decades ago, depositing or withdrawing funds from the local bank commonly required a significant time investment, typically comprised of waiting on

line for an in-person interaction with a bank teller. Technology has rendered this resource-intensive process largely obsolete in favor of now-ubiquitous ATMs and, more recently, Internet-based and even mobile device-based transactions.

Despite the tremendous growth of technology that now permeates our lives, the majority of clinical research conducted today relies primarily on the same resource-intensive, inperson visits to brick-and-mortar facilities that have been in place since the inception of modern medicine. The great majority of Americans have an Internet connection, and a growing majority own smartphones. In the Health eHeart Study, we seek to leverage this wealth of pervasive technology to conduct clinical research more efficiently. As heart disease remains the most common cause of death in the U.S., surpassing all cancers combined, we believe it is an ideal topic of investigation for this new study that aims to capture big data.

The efficiency afforded by technology is particularly advantageous to the study in several different ways. First and foremost, by using Internet-based surveys and activities, participants can contribute from the convenience of their home, work, or anywhere that has an Internet connection. Second, the frequency and density of data that can be collected far exceeds that of conventional cohort studies. Third, this infrastructure can be used to collect “real-time” and “real-life” data. Fourth, interactive, bidirectional study communication between investigators and participants can be achieved in a manner that is particularly feasible, rapid, and nimble. Finally, the study is readily scalable, without significant added cost when jumping from 100,000 to 1,000,000 enrolled participants.

Participants will be recruited via word of mouth, social media (including Facebook, Linkedin, and Twitter), and traditional media (with descriptive articles already published in The New York Times, Wall Street Journal, Science magazine, and the San Francisco Chronicle; radio announcements on National Public Radio, and television broadcasts via Fox News and the BBC). In our initial launch, several thousand participants were enrolled over a few months, representing significant geographic diversity throughout the U.S. and around the globe. Through a variety of strategic partnerships, we hope to achieve our goal of enrolling and retaining 1,000,000 participants over the next few years.

The study is multifaceted and designed to be modular.

It has been approved by the UCSF Committee on Human Research, and all participants must provide informed consent 16 17

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via an electronic signature. The “base” experience that all participants undergo involves filling out multiple online surveys.

Given an adaptive design, these surveys appear similarly and function well whether completed on a personal computer, tablet, or smartphone. The surveys are grouped within individual sections, and the various sections make up a given “e-visit.” The entire e-visit can be completed in one sitting approximately within an hour, but participants are welcomed to take up to a few weeks if necessary. The content of the surveys involves questions regarding demographics, medical and family history, and several validated instruments to categorize and/or quantify quality of life, physical activity, and symptoms. Many of the surveys are triggered depending on certain answers. For example, those who indicate that they have a diagnosis of heart failure receive additional validated surveys regarding heart failure symptoms, just as those who indicate that they have atrial fibrillation will receive follow-up surveys specific to that disease. The first e-visit will be the first activity encountered upon enrolling in the study, and subsequent e-visits to obtain follow-up data, any changes in history, and any incident hospitalizations or emergency department visits will be sent every six months.

In addition to these e-visits, participants will have the opportunity to interact with multiple ongoing activities. For example, we recently introduced the Profile Page. On this web page, participants can enter their blood pressures, pulse measurements, waist and hip measurements, weight, and medications. Many of these data fields are accompanied by questions related to the acquisition of the measurement, such as whether blood pressure was measured by a doctor, at a pharmacy, or by oneself. The participant can view a summary of the measurements and medications and soon will have the option to e-mail or download a summary table. The hope is that these tables may be helpful to participants in tracking their own health records and communicating with their health care providers.

The Profile Page also includes options to “connect” to several devices. For example, participants can link data from Bluetooth-enabled blood pressure cuffs, scales, and activity monitors. Once connected, this means that all the data from their device will be imported directly to the study. Again, participants can use the automated tables on the website. And, most important, this rich data, reflecting repeated measures taken at home or on the move, can be rigorously studied in relationship to cardiovascular risk factors and ultimately to cardiovascular outcomes. Many people already own such scales and blood pressure cuffs, and more and more are using activity sensors (such as Fitbit or Jawbone Up) to track their www.sfms.org

activity. We believe such nearly continuous data will add great value to the study and provide us with a novel glimpse into the relationships between natural physiologic parameters and important outcomes.

We are also in the process of launching mobile applications (“apps”) that can be used to measure several parameters relevant to cardiovascular physiology. We are working with Ginger.io to use its sophisticated algorithms to track activity, screen time, and number of calls and texts as predictors of health.

While the cross-sectional data provided by the baseline surveys holds inherent value, the utility of collecting these data will be fully realized when incident events are ascertained. The follow-up e-visits will be critical, but we will also employ additional strategies to assure the validity of participant reports and enhance the sensitivity and specificity of outcome ascertainment. First, we will obtain electronic Health Insurance Portability and Accountability Act (HIPAA) consent to collect medical records. In addition to linking with EMRs via records that will dump directly into the research database, we will leverage the fact that all individuals will soon own their entire electronic medical record via the Blue Button Plus initiative, a mandatory effort that is a part of the Affordable Care Act. Finally, we will use applications downloaded to smartphones to facilitate ongoing communication regarding health care use.

More broadly, the study has been designed to serve as a platform for a new way of conducting clinical research. We are

In

in discussions with multiple partners in academia, industry, and government to develop and implement cutting-edge, lowcost, novel research projects. We anticipate that Health eHeart participants will be invited to enroll in multiple sub-studies, such as randomized controlled trials of certain interventions or observational studies to test out the latest and most promising technologies related to diet, physical fitness, and cardiovascular health.

The Health eHeart team is very excited to initiate this bold project and proud to generate this global cohort from San Francisco. We invite all individuals age eighteen and older to join and, in turn, welcome all those interested to invite their friends, family, and colleagues. We require engaged participants who will be sufficiently motivated to stay with us over time, and we in turn are doing our best to make the study easy, enjoyable, and fulfilling. Like all other studies, this important research ultimately relies on the altruistic spirit of the individuals who are willing to contribute, and we are confident we will ultimately translate this big data into discoveries that will meaningfully enhance our ability to predict, prevent, and treat heart disease.

To learn more about the study, please visit https://www.

Health-eHeartStudy.org.

Gregory M. Marcus, MD, MAS, is the director of Clinical Research, UCSF Division of Cardiology, and an associate professor of medicine at UCSF.

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October 2013 San Francisco Medicine

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Big Data, Big Medicine

Advancing medical research The ACC National Cardiovascular Data Registry Ralph Brindis, MD, MPH, MACC, FSCAI The holy grail for clinical research for more than forty years has been harnessing the power of randomized clinical trials (RCTs). The advantages are well

known. The randomization process, ideally with a doubleblind methodology, helps minimize multiple biases that could be in play when performing a clinical study, along with minimizing the presence of unmeasured patient confounders that also could greatly affect the clinical results of a study and lead to unwarranted conclusions. RCTs are, however, extremely expensive to perform, with a modest study of 5,000–10,000 patients costing 30–50 million dollars, even with a relatively modest longitudinal follow-up interval.

Furthermore, infrequent adverse outcomes related to a device or treatment may not be picked up in a modest-sized RCT. There had been increasing reliance on “surrogate markers” to assess outcomes in RCTs. Increasing RCT examples of how “benefits,” as assessed by surrogate markers (e.g., tight HgbA1C-level control in diabetics), have not necessarily translated into true benefits with longitudinal patient clinical outcomes have led to the need for more extensive and expensive RCTs or the pursuit of alternative mechanisms such as using big data obtained through national registries to assess efficacy and safety of devices and procedures.

The NCDR

With a mission centered on the collection and use of data to support quality improvement, the American College of Cardiology (ACC) launched the National Cardiovascular Data Registry (NCDR) (www.ncdr.com) fifteen years ago. There were several key reasons for the development of the NCDR. First, the cardiovascular profession wanted to demonstrate leadership in defining and improving quality of care. Second, individual hospitals or practices can collect their own performance data but rarely have the ability to accomplish regional or national benchmarking on their own. Third, data collection needs to be standardized and risk-adjusted for comparisons to have validity. Finally, the data elements collected should support measurements of care that reflect current evidencebased clinical practice guidelines and quality metrics. The ACC, in collaboration with the American Heart Association (AHA) and other professional organizations, develop the data standards, guidelines, and quality measures for cardiovascular disease.

Currently, the NCDR includes seven registry programs.

More than 2,500 hospitals across the U.S. participate in at least one NCDR program. The NCDR is a $25 million yearly investment for the ACC, with seventy NCDR staff supporting its operations. The CathPCI registry alone includes more than 18 19

San Francisco Medicine October 2013

15 million patient records. The PINNACLE ambulatory care registry program, assessing secondary prevention in CAD, HTN, and HgbA1C control and anticoagulation strategies in atrial fibrillation, has more than 1,000 physicians participating with well over 4 million patient records. Additional NCDR registries focus on ICD implantation for primary and secondary prevention of sudden cardiac death, with the CARE registry assessing carotid artery revascularization; the IMPACT registry collecting data on catheterization lab interventions in congenital heart disease; the ACTION-GWTG-ACS registry overseeing myocardial infarctions; and the recently launched STS-ACC TVT registry, which assesses transcatheter valve therapy, already including 250 hospitals and well over 9,000 transaortic valve replacements (TAVRs) in its database. It is important to emphasize that the NCDR registry programs are multiorganizational, given that the ACC partners with many other professional organizations in specific areas where appropriate. The TVT Registry not only has the Society of Thoracic Surgery (STS), the ACC, and the Society of Cardiovascular Angiography and Interventions (SCAI) but also both the pre- and post-market representatives from the FDA as well as representatives from CMS actively overseeing the registry. A TVT advisory group is represented by multiple professional societies, patient representatives, and relevant quality organizations along with industry colleagues. It is hoped that, with the TVT model of broad-based stakeholders, the U.S. might achieve a more rational dispersion of innovative technology into the marketplace.

The NCDR and Outcomes Research

A key aspect of the NCDR mission is to leverage the clinical registry data for health outcomes research. In a study using CathPCI registry data, Kutcher et al compared hospitals performing PCI with and without onsite cardiothoracic surgery—a topic of considerable debate with regard to quality of care and patient outcomes, yet, at the time of the study, lacking in evidence. This study found that PCI centers with off-site cardiac surgery had similar procedure success, complications, emergency cardiac surgery rates, and risk-adjusted mortality.

In a study using ICD Registry data, Curtis et al compared the outcomes of patients who received an ICD implantation by an electrophysiologist or a non-electrophysiologist. They found that non-electrophysiologists currently implant about 30 percent of the ICDs in the U.S. yet implantation by a nonelectrophysiologist was associated with a significantly higher risk of periprocedural complications. Moreover, these patients were less likely to receive cardiac resynchronization therapy when it was indicated. It is very unlikely that a question like www.sfms.org

this would ever be evaluated in a randomized clinical trial. In a study using data from the ACTION Registry, Diercks et al. evaluated the proportion of patients with ST-segment elevation myocardial infarction who receive a pre-hospital ECG. They found that just over one-quarter of patients transported by emergency medical services receive a pre-hospital ECG; yet patients who do receive a pre-hospital ECG were more likely to receive reperfusion therapy and had shorter doorto-reperfusion times, and there was a trend toward lower inhospital mortality.

In a study funded by the Food and Drug Administration, a subset of hospitals participating in the CathPCI registry participated in a detailed investigation of bleeding complications associated with various groin closure devices. This study revealed that one device, VasoSeal, was associated with a significantly higher rate of vascular complications. The results of this study led to the removal of the device from the market.

The ASCERT study reported in the NEJM last year combined data from the NCDR CathPCI registry with the STS Registry and its CABG database with longitudinal administrative data from CMS to study comparative effectiveness in relation to long-term outcomes of coronary revascularization. Another study funded by AHRQ assessed safety and efficacy of drug-eluting coronary stents (DES) after worrisome reports of acute stent thrombosis questioned the safety of drugeluting stents, representing a potentially huge public health issue given the millions of patients in the U.S. already with drug-eluting stents implanted. Data from more than 260,000 patient records from the NCDR CathPCI, including records of patients who had received both DES and bare metal stents (BMS), were merged through ingenious probabilistic matching mechanisms with thirty-month CMS longitudinal administrative data. The goal was to look at death, repeat revascularization, stroke, and rehospitalization for either MI or bleeding. The study showed that DES were safe and effective without a signal for increased risk of stent thrombosis. Using the power of the NCDR database and longitudinal matching of CMS data, this study was performed for less than $100,000.

An RCT involving 260,000 patients would have cost billions.

The NCDR as the Infrastructure Engine for RCTs

Imagine the power of tapping into the large river of data produced by the registry as an opportunity to “cast a fishing line” into that river to pose important clinical questions in a prospective manner. The NCDR, in partnership with the Duke Clinical Research Institute, has now built the infrastructure necessary to conduct clinical trials among interested NCDR participant sites. The first study performed using this new paradigm was SAFE-PCI that randomized women undergoing PCI between the femoral and transradial approach, assessing safety and efficacy of the transradial strategy. The NCDR hospital-based study was found to be substantially more efficient than “de novo” clinical trials, with a remarkable ability to not only recruit participant sites more rapidly but to also have a much broader patient representative sample enrolled from all of the participating sites. Using the clinical registry data already being collected allowed the local research coordinators www.sfms.org

to enter only an additional 30 percent of the needed research data. The overall financial savings in running the RCT using the NCDR infrastructure versus the traditional RCT model was huge. The TVT registry based on this success is collaborating with the FDA, CMS, and industry embarking on performing post-approval studies required for TAVR devices, along with investigational device exemption (IDE) studies for what in the old paradigm would be called “off-label” use. Going forward, clinicians, payors, and patients will have the benefit of better understanding the safety and efficacy of these “off-label” device applications through the registry—something never accomplished adequately in the past.

The Future

NCDR registries will increasingly capture longitudinal care and patient outcomes, moving toward a model of true “patient-centered” registries. This shift in registry big data collection, moving from what was previously a procedurally oriented episode of care to longitudinal assessment of true clinical outcomes, will reap huge benefits in applications for medical research purposes. An impressive post-market surveillance registry-based strategy of both medical devices and medications has already been implemented with essentially “real-time” surveillance mechanisms under the Sentinel program initiated by the FDA and the NCDR. Finally, the future will incorporate the integration of the big data from patient health records (EHRs) directly into NCDR registry programs, allowing the realization of a truly patient-centric health registry, integrating data from episodes of care (procedures, clinic visits, hospitalizations) with critical health information from patients between episodes of care (e.g., symptom and functional status, medication use, and measurements such as home blood pressures).

Dr. Ralph Brindis is a clinical professor of medicine at the University of California, San Francisco, and serves on the affiliate faculty of the Philip R. Lee Institute of Health Policy Studies at UCSF. He is the senior medical officer of External Affairs for the ACC National Cardiovascular Registry (ACC-NCDR), currently overseeing seven cardiovascular national registries assessing cardiac catheterization and angioplasty, implantable defibrillators, carotid stenting, percutaneous valve implantation, acute coronary syndromes, ambulatory cardiovascular medical management, and congenital heart disease. Dr. Brindis was the president of the American College of Cardiology (ACC) from 2010 to 2011 and the senior advisor for cardiovascular disease for the Northern California Kaiser Permanente Medical Group from 2003 to 2012. He received his undergrad education at MIT and has a MPH from UCLA. He graduated summa cum laude from Emory Medical School. His graduate medical training was performed at UCSF as a resident and chief resident in internal medicine and as a cardiology fellow.

October 2013 San Francisco Medicine

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Big Data, Big Medicine

From Intuition to Science Big Data Helps Run Your Practice Efficiently Mudit Garg and Brent Newhouse How do you plan? Every day, care providers and managers make critical decisions regarding how they manage their departments. They must answer questions such as, “If I don’t know how many patients are coming tomorrow, how do I staff appropriately?” and “How do I keep wait times down?” or, for surgery centers, “How should I optimally allocate OR blocks?”

These are critical operational decisions. They impact not only the efficiency of a clinical service but, importantly, the quality of care that is delivered.

Getting these decisions wrong means potentially turning patients away, violating nursing ratios, creating bottlenecks in patient flow, or worse. Getting them right means improving resource use, effectively managing cost, and creating a more satisfying patient experience.

But today, many clinicians and managers are forced to “fly blind.” They are left to make operational decisions based on some combination of intuition, past habits, and perhaps a spreadsheet or two.

Imagine an Emergency Department manager, Peter, who has to plan staffing for the upcoming week in his department.

Intuitively, he believes that Mondays and Fridays are busier days, and that the volume usually starts to pick up around 2:00 p.m. So he assigns an extra physician to the afternoon swing shift, and he starts the evening nursing shift a few hours earlier than usual. Though the staff is a little resistant to making the last-minute change, they go ahead. The change feels like the right one, Peter decides.

In reality, it might turn out that Mondays and Fridays are busy for a variety of environmental factors, some of which are about to change in the upcoming week. And as for the 2:00 p.m. spike, the data shows that the spike starts at different times of the day depending on seasonal and other external factors, which Peter does not consider. But it’s hard to blame him; it’s almost impossible to discern these nuanced statistical relationships without some sort of computational help.

This is where the idea for our company, analyticsMD, was born. It is possible to supports clinicians and hospital managers with these operational decisions by converting data into usable and actionable insights.

Forecasting Demand and Staff Planning

As the anecdote above highlights, patient demand can be difficult to predict in many departments in hospitals or clinics. Sometimes patient demand can appear almost completely random. Some days are busy, others aren’t. Some days very sick patients come in, other days they don’t. This apparent randomness can make it difficult to choose the appropriate level of staffing. In response, many department managers and 20 San 21 SanFrancisco FranciscoMedicine Medicine October October2013 2013

clinicians choose a flat level of staffing—again, largely based on historical experience and intuition—and then make adjustments right before or during shifts.

This method of demand planning has costs, both visible and invisible. The most obvious cost to last-minute adjustments are the overtime, on-call, or agency hours that must be incurred to meet an unexpectedly large demand. But more subtle costs exist as well. Sudden changes in schedules can be disruptive to staff and cause dissatisfaction and, over the long term, higher turnover rates. Additionally, a last-minute scramble to find nurses can put statutory patient ratios at risk of violation. In some cases, a consistent tendency to over- or under staff can result in gaming by staff. For instance, if it is commonly known within a team that “we’re always overstaffed at the end of the week,” some team members might be inclined to call in sick. This makes it even harder to properly plan ahead.

It is interesting to note that in many other industries— consumer packaged goods, retail, and manufacturing, among others—rigorous mathematical models are used to forecast demand so that sufficient supply can be allocated. Large teams of analysts use complicated tools to predict and plan for every potential demand scenario, so just the right number of “widgets” can be ready for consumers. But these practices are much less common in clinical environments, where their use could save lives. Managers and clinicians are left to their intuition. The absence of rigorous, data-driven forecasting practices in clinical settings is especially perplexing when one also considers the vast quantity of data that most physician offices and hospital departments collect in their health IT systems.

But the data is rarely used for these operational purposes.

Optimizing Patient Flow

In addition to staff planning, a second important area of operational decision making is patient flow optimization. Today, it is common for hospitals and clinics to carry out multimonth “transformations” of a given department, wherein members of that department work with a lean guru to redesign aspects of the care delivery process. The Emergency Department presents a classic example. In such a project, nurses, physicians, and staff will brainstorm improvements (“Let’s set up a low-acuity FastTrack”), implement those ideas, then measure and track the outcomes (in this example, perhaps focusing on patient length of stay).

With strong support from leadership and an engaged front line, these performance improvement projects can drive meaningful gains in key metrics. But what happens when the

Continued on page 22 . . . www.sfms.org

Big Data, Big Medicine

Improve Care, Lower Cost Brown & Toland Uses Data for Better Health Outcomes Andrew Snyder, MD, and Keith Pugliese Brown & Toland Physicians’ comprehensive collection of health data and information is the catalyst

for a number of care coordination programs and activities designed to improve quality of care and reduce health care costs for all of our patients.

The data warehouse is the foundation that provides information to help coordinate care for close to 60,000 commercial, PPO, and Medicare patients in accountable care initiatives at Brown & Toland. Two of these projects—the Centers for Medicare and Medicaid Services (CMS) Medicare Pioneer ACO and an ACO with Blue Shield and California Pacific Medical Center (CPMC) for City of San Francisco employees and retirees—are already reducing costs and improving care for patients.

Applying the Triple Aim Approach

Developed initially by the Institute for Healthcare Improvement, and later adopted by CMS and now part of the national health care lexicon, the Triple Aim of improving the patient experience of care (patient satisfaction), improving the health of populations (quality outcomes), and reducing the per capita costs of health care is key to Brown & Toland’s approach to an accountable care model.

To achieve the three-part aim, Brown & Toland uses a “care management convener” approach to care, with key measurements such as reducing the rate of unnecessary or unplanned readmissions (including tracking readmissions by specific disease states, such as congestive heart failure or chronic obstructive pulmonary disease) and tracking the improvement of certain disease indicators (such as diabetes [A1C, LDL] and cardiovascular health [blood pressure, BMI, and smoking]).

The Brown & Toland model focuses on reducing avoidable acute inpatient admissions and unnecessary emergency room visits. Additionally, Brown & Toland also uses a “Transitions of Care” program that helps coordinate services patients will need after they are discharged from acute care facilities.

These services may include medication instruction, safety checks, and self-management education.

Most important, Brown & Toland’s care management teams in San Francisco and the East Bay (as part of Alta Bates Medical Group) work with patients and their doctors to determine when care management activities, preferably proactive activities, would be clinically beneficial.

Here are some real-life examples of how sharing health care data and coordinating care has benefited patients and reduced costs.

A 57-year-old female with multiple diagnoses, includwww.sfms.org

ing asthma, diabetes, obesity, sleep apnea, and hypertension, was discharged from CPMC after treatment for pneumonia. At discharge, a Brown & Toland in-patient nurse referred her to a Brown & Toland health coach for a transition-of-care call.

During the call, the woman noted that CPMC staff had already scheduled a physician follow-up appointment and she had no concerns about medications. She did, however, request additional support for other ongoing health issues. During an additional review of the patient’s health record, the health coach discovered that her blood sugar levels were high and suggested she see her primary care physician. Later, the health coach assisted the woman in obtaining a CPAP machine for her sleep apnea. With the support of her primary care physician, the woman also quit smoking. Ongoing weekly health coaching calls have built on the woman’s sense of success in quitting smoking and have motivated her to consider a weight-loss program as her next step on the road to health.

In another example, a 68-year-old female with Parkinson’s disease and advanced pancreatic cancer was admitted to CPMC. The cancer had recently progressed to her liver and lungs. When discharged, a transition-of-care call was made by a Brown & Toland care manager, who reviewed her health care record and recent care at CPMC. The care manager assessed that the patient was too weak to walk down steps for her chemotherapy treatments and arranged for transportation. The care manager, building on the patient’s desire to be more independent, helped her set goals and encouraged physical therapy. After about four weeks, the patient’s strength had progressed to the point that the ambulance service was suspended and her daughter was able to take her to her appointments.

In the Brown & Toland model, patients at risk are assessed using robust population-health predictive analytical tools. Those patients with higher risk scores are matched to the correct programs for appropriate care management interventions. To help achieve its goals, Brown & Toland uses a multidisciplinary approach, including a care management team of physicians, nurses, and social workers.

Medicare Pioneer ACO

Brown & Toland was one of thirty-two health care organizations nationally that were selected to participate in the Pioneer ACO pilot. For 2012, Brown & Toland was held accountable for the total cost of care, including care provided by its physicians as well as care provided by others outside of the our network, for close to 18,000 Medicare fee-for-service beneficiaries aligned with 190 Brown & Toland doctors. Over-

Continued on page 22 . . .

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Improved Care, Lower Cost Continued from page 21 . . . all, Brown & Toland’s Pioneer ACO model was one of the top performers nationally for 2012 and performed at six percent below the financial benchmark set by the CMS Innovation Center, saving $10.6 million, or about 12 percent of the total gross savings achieved overall in the first year of the Pioneer ACO program.

San Francisco Health Services System ACO

Additionally, a Brown & Toland ACO project that began in 2011 with Blue Shield of California and CPMC helped reduce costs and improve care for more than 21,000 employees, dependents, and retirees of the San Francisco Health Service System. After our first year in partnering with Blue Shield and CPMC, we saw dramatic reductions in use with concomitant improvement in quality metrics. The accountable care project delivered an 8.8 percent reduction in admissions per 1,000 members, a 13.4 percent reduction in inpatient days per 1,000 members, and a 5.1 percent reduction in the average length of stay for inpatient admissions. Significant cost savings were also achieved by having patients switch to less costly but just as effective generic medications.

From Intuition to Science Continued from page 20 . . . project ends a few months later, and the lean guru or transformation team moves onto the next department? Often, the results slowly begin to erode, necessitating a string of follow-on engagements and, perhaps, additional and costly consultant time.

Usually the deterioration happens because the department team is left without the tools required to parse through performance data, identify trends, and decipher root causes.

For example, without the right analytics tool, it would be extremely difficult for an ED team to determine that a recent increase in length of stay is actually caused by a critical delay in one part of the discharge process, which in turn leads to beds staying occupied for much longer than needed. Such a delay would then ripple through the entire ED flow, causing longer wait times, more patients to depart before treatment, and greater patient dissatisfaction. In this example, seeing the trend and extracting a root cause without a properly designed tool would be extremely labor intensive, or, alternatively, the staff would be left to simply rely on intuition. These same challenges occur in any other hospital department, surgery center, or clinic that attempts operational performance improvement projects.

Because of the savings generated by this ACO, San Francisco Health Service System’s Blue Shield premiums will not increase for the 2014 plan year.

Brown & Toland PPO ACOs

In addition to the Pioneer ACO and the ACO for city and county of San Francisco employees and retirees, Brown & Toland also participates in accountable care projects with Aetna and Cigna for preferred provider organization (PPO) patients.

These ACO initiatives involve close collaboration between Brown & Toland and each PPO, to identify opportunities for providing care management and quality program services.

While our accountable care approach is still evolving, we learn from each project and adapt as necessary.

By gathering the knowledge, ideas, and experiences of physicians and patients, Brown & Toland continuously works to improve the effectiveness and adoption of our accountable care initiatives to fully achieve the Triple Aim.

Andrew Snyder, MD, is chief medical officer of Brown & Toland. Keith Pugliese is vice president of Accountable Care and Public Policy for Brown & Toland Physicians.

customized dashboards to monitor performance in their work areas, receive SMS and e-mail alerts when important events take place, and share their findings with one another. Additionally, our proprietary algorithms can automatically find hidden root causes behind performance trends. Our forecasting tool applies machine learning techniques on a variety of signals to predict census in advance of shifts, so managers can set plans that require fewer last-minute changes. analyticsMD is a SaaS (software as a service) product, meaning it resides on the Web and can be securely accessed from a clinician’s office, home, or mobile device and it is HIPAA-compliant. To learn more about it, see www.analyticsMD.com.

Mudit Garg is CEO and cofounder of analyticsMD. He is a serial entrepreneur and technologist, and he holds advanced degrees in electrical engineering and business from Stanford University. Brent Newhouse is head of Product & Operations and also a cofounder of analyticsMD. He holds an advanced degree in management science and engineering from Stanford and has a background in technology strategy and operations. Both have extensive experience leading performance improvement projects in hospitals across the West Coast. The analyticsMD team is based in Palo Alto, California, and their website can be found at www.analyticsmd.com.

Our Solution

analyticsMD is our effort to make robust, optimized decisions about patient flow and demand planning available to clinicians. It allows hospital and clinic staff to create intuitive,

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Slate of candidates SFMS 2013 Election Pursuant to the San Francisco Medical Society Bylaws Article X Section 2-Nominations, the Nominations Committee renders in writing the following slate of candidates for the 2013 SFMS election. This slate was read at the September 9, 2013, General Meeting, at which time the SFMS President called for additional nominations from the floor.

2014 Officers | Term 2014

SFMS Board of Directors

For President-Elect Roger S. Eng, MD For Secretary Richard A. Podolin, MD, FACC For Treasurer Man-Kit Leung, MD For Editor Gordon L. Fung, MD, PhD

Term: 2014-2016 Seven candidates to be elected to the SFMS Board of Directors William J. Black, MD, PhD, FACP Benjamin C.K. Lau, MD (Incumbent Director) Ingrid T. Lim, MD, FACEP, FAAEM Keith E. Loring, MD (Incumbent Director) Todd A. May, MD Ryan Padrez, MD (Incumbent Director) Adam Schickedanz, MD (Incumbent Director) Rachel Hui-Chung Shu, MD (Incumbent Director) Paul J. Turek, MD, FACS, FRSM

SFMS Nominations Committee

Term: 2014-2015 Four candidates to be elected to the SFMS Nominations Committee James L. Chen, MD Patricia J. Galamba, MD Vanessa E. Kenyon, MD Zuoqin (Zoe) Tang, MD Amy E. Whittle, MD

American Medical Association Delegate Term: 2014-2015 One candidate to be elected as AMA Delegate Robert J. Margolin, MD (Incumbent Alternate)

Young Physicians Section Delegate to the CMA House Term: 2014-2015 One candidate to be elected as YPS delegate.

Stephanie Oltmann, MD (Incumbent Alternate)

Delegates to the California Medical Association House of Delegates Term: 2014-2015 The candidates receiving the highest number of votes will serve as Delegates; the rest will be Alternate Delegates or on the wait list. The President-Elect automatically becomes one of the Delegates, according to the SFMS Bylaws.

Ameena T. Ahmed, MD, PhD Brittany Blockman, MD George A. Fouras, MD (Incumbent Delegate) Katherine E. Herz, MD (Incumbent Alternate) Keith E. Loring, MD (Incumbent Alternate) Edward T. Melkun, MD David R. Pating, MD Richard A. Podolin, MD, FACC Tristan Sands, MD, PhD Judy L. Silverman, MD (Incumbent Alternate) Brigitte Watkins, MD Elizabeth K. Ziemann, MD

American Medical Association Alternate Delegate Term: 2014-2015 One candidate to be elected as AMA Alternate Gordon L. Fung, MD, PhD

NOTES

2013 President-Elect Lawrence Cheung, MD, automatically succeeds to the office of President.

2013 President Shannon Udovic-Constant, MD, automatically succeeds to the office of Immediate Past President.

Member voting will take place ONLINE ONLY. In order to place your vote, we must have your e-mail address in our database. Please provide us with your e-mail address if we donâ&#x20AC;&#x2122;t already have it. Paper ballots will NO LONGER be mailed. Please look for a special e-mail from SFMS on October 22 with detailed information regarding the online voting process, as well as the link to the online ballot. If you are unsure about whether or not we have your e-mail address, please e-mail membership@sfms.org.

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CANDIDATE BIOGRAPHIES President-Elect

Secretary

Roger S. Eng, MD, MPH, FACR

Treasurer Richard A. Podolin, MD, FACC

Man-Kit Leung, MD

Also Candidate for CMA Delegation

Dermatology

Cardiology

Otolaryngology

Head & Neck Surgery

Current Job Positions and Hospital and Teaching Affiliations

Private practice with one partner (Remo Morelli, MD) and affiliated with St. Mary’s Medical Center.

Private practice in small group; affiliations with Chinese Hospital, St. Francis Memorial Hospital, CPMC, St. Mary’s Medical Center; Adjunct Clinical Instructor, Stanford University School of Medicine Department of Otolaryngology – Head & Neck Surgery

SFMS: Director 2009–12, Executive 2010–11, 2013, PAC 2011–13, Nominations 2011; CMA: Board of Trustees 1997–98, 2003–07; Delegate/ Alternate Delegate 1995–2013; Young Physicians Section, Chair 2001–02; IT Committee, Chair 2004–08; Committee on Nominations 1997–98, 2003–07; Long-Range Planning Committee 2003–07; Chair, CMA Website 2006–07; Health Care Finance Technical Advisory Committee 2004; Committee on Medical Service 1998–99; CMA House of Delegates 2012 Reference Committee C

I have served on the Board of the SFMS for the past three years, and for many years I was a delegate to the CMA from the California Chapter of the American College of Cardiology.

SFMS Secretary, SFMS Board of Directors, SFMS Executive Committee, SFMS PAC (Vice Chair), SFMS Nominations Committee, Chinese Hospital liaison to SFMS, CMA Alternate Delegate to HOD, CMA at-Large Delegate to COL

AMA offices: AMA Delegate 1996–97; AMA-RPS Delegate 1995–97; AMA-YPS Delegate 1998–99 (Vice Chair, CMA YPS delegation); President, California Radiological Society; Treasurer, San Francisco Bay Radiological Society; Kona Healthcare, Chief Medical Officer; Chinese Community Health Care Association IT Committee 2006–present; Carestream Physician Advisory Board 2005–present; American College of Radiology, Councilor, 2008–present; Chinese Hospital, Medical Executive Committee 2004–2010

I served as Vice Chief of Staff and Chairman of the Quality Committee at St. Mary’s Medical Center for four years, and then as Chief of Staff for four years. I have been President of the San Francisco Heart Association and a District Councilor for the California Chapter of the American College of Cardiology. Currently I serve on both the Community Board and the Foundation Board of St. Mary’s Medical Center.

President, Golden Gate Radiology Medical Group; Chief of Radiology, Chinese Hospital

SFMS/CMA Committees or Offices

Additional Relevant Experience

Why Are You Interested in Serving?

Participating in our local medical society is both a privilege and a professional responsibility. As SFMS President-Elect, I work with our diverse membership from medical students to large group physicians to best serve San Francisco’s physician members and their patients. www.sfms.org

In this period of fundamental change in our health care system, physicians need an advocate and a partner. As a delegate to the CMA from the California Chapter of the ACC, I learned that the activities of the CMA directly affect the viability of medical practice in this state.

I am interested in continuing my service to the SFMS membership as your Treasurer next year. In this position, I hope to strengthen our financial stability so that we can continue to champion causes for and protect the welfare of physicians and patients, especially throughout this period of health care reform.

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CANDIDATE BIOGRAPHIES Board of Directors

Editor

William J. Black, MD, PhD, FACP

Gordon Fung, MD, PhD

Benjamin C.K. Lau, MD Incumbent Director

Also Candidate for AMA Delegation

Cardiovascular Diseases

Internal Medicine

Physical Medicine and Rehabilitation

Current Job Positions and Hospital and Teaching Affiliations

Clinical Professor of Medicine, UCSF Medical Center; Director of Cardiac Services at UCSF Medical Center at Mount Zion; Director of Asian Heart & Vascular Center; Director of Electrocardiography Laboratory at Moffit/ Long Hospitals

Chief Medical Officer, Physician Foundation Medical Associates; Medical Staff, California Pacific Medical Center

Physiatrist, with a solo private practice in San Francisco. I see mainly musculoskeletal pain, stroke, disabled, and industrial injury patients. I am also a medical acupuncturist for pain management.

Past CMA delegate from San Mateo County Medical Association; no current SFMS or CMA offices

SFMS Board of Directors, 2010-13. I have been on the nomination committee since 2013.

SFMS/CMA Committees or Offices

SFMS Editor, 2010 to present; Past President, SFMS; CMA Delegate since 2000; Member of Council of Scientific Affairs, CMA, 2004-present; IMQ Surveyor since 1994

Additional Relevant Experience

Why Are You Interested in Serving?

Communications, education, and learning are the jobs of the editor. Over the past two years I have learned much more about the topics and issues facing the clinicians in practice in the community as well as academics. Working with the SFMS staff, Editorial Board, and Executive Committee and keeping the communication channels open with the membership and other interested parties that interface with SFMS through San Francisco Medicine has been one of the highlights of my involvement with SFMS. In a sense, San Francisco Medicine, our award-winning journal, is one of the oldest still-viable forms of social media used by the physician community serving San Francisco Bay Area. I truly cherish my time on the board and look forward to serving as your editor for 2014.

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I have had the privilege of serving as a board member and president of the San Mateo County Medical Association, and as a delegate to the CMA, when my practice was in San Mateo County. I currently practice in San Francisco. I have also served in various medical director and leadership roles within medical groups related to quality, medical informatics, clinical practice redesign, business processes, and clinical operations.

I am also in the board of governors of a nonprofit organization called CYC (Community Youth Center). It helps to support and manage teenage issues in San Francisco.

Why Are You Interested in Serving?

Health care reform, information technology, and the looming shortage of physicians are bringing massive change for physicians, necessitating active physician leadership and advocacy at all levels. I have been privileged to previously serve the physicians of San Mateo County and hope to continue doing so, now practicing in San Francisco.

San Francisco Medicine October 2013

The past three years allowed me to contribute to the upkeep of policy and foundation in our medical community. I want to continue contributing to a common goal that sets a fair, threat-free, and humane medical practice environment, and a better served San Francisco Bay Area community.

www.sfms.org

Ingrid T. Lim, MD, FACEP, FAAEM

Keith Loring, MD

Todd A. May, MD

Incumbent Director

Also Candidate for CMA Delegation

Emergency Medicine

Emergency Medicine

Family Medicine

Current Job Positions and Hospital and Teaching Affiliations

Senior Emergency Physician, the Permanente Medical Group; Kaiser Permanente, San Francisco Medical Center; President, Professional Staff, Kaiser San Francisco (elected office); Chief, Continuing Medical Education, Kaiser San Francisco; Residency Site Director, UCSFSFGH Emergency Medicine Residency Program; Assistant Clinical Professor, Emergency Medicine, UCSF

Attending Emergency Physician, Emergency Department, CPMC Davies Campus

Chief Medical Officer, San Francisco General Hospital; Primary Care Physician, Family Health Center, SFGH; Hospitalist Attending Physician, SFGH; Professor, Family & Community Medicine, University of California, San Francisco

I have been a SFMS member since 2007. For the past year, I have served as the Kaiser Permanente, San Francisco Medical Center Liaison to the SFMS Board, and I have attended all Board meetings.

Board of Directors 2011-13 and 2009; SFMS Treasurer 2010; Alternate Delegate to CMA House 2011-13; Finance Committee 201013; Executive Committee 2009-11

I served as SFGH Liaison to the SFMS Board of Directors during my term as Chief of the Medical Staff at SFGH, 2009-11.

From 2009-2010, I served as the President of the California Chapter of American Academy of Emergency Medicine (CAL-AAEM), after being on the Board of Directors for three years. Our organization was committed to the principles that every individual should have unencumbered access to quality emergency care, that the practice of emergency medicine is best conducted by a board-certified emergency physician, and that fair and equitable practices should be the standard.

SF DPH Psychiatric Crisis SOC Committee Member, 2011 to present; SF DPH Dore (Psychiatric) Urgent Care Center Steering Committee, 2007-2011; SF Emergency Physician’s Association President, 2009-2010; Reference Committee Member, CMA House of Delegates, 2011-2012; Vice Chief of Staff at St. Mary’s Medical Center, 2008-2010; Regional Medical Director, California Emergency Physicians, 1/2008 to 8/2010

I have been closely involved with clinical operations at SFGH for the last 18 years, in both primary care and inpatient services. I have assumed substantial leadership roles at the SFGH campus. I am a member of the San Francisco Department of Public Health Integrated Steering Committee, which guides DPH clinical and public health functions.

We’re at a pivotal crossroads with health care in this country. No matter what practice setting we work in, physicians must have a voice at the legislative table, or someone else will determine how we practice medicine and care for our patients. I want to be part of this.

I want to be a part of the answer to the evolving challenges currently posed by the implementation of the Affordable Care Act and the brewing assault on MICRA. Therefore, I value greatly the opportunity to continue in my roles on the board and as part of our delegation to the CMA as one of the best ways to bring to bear my skills and experiences on these efforts.

This is a dynamic time in health care, requiring enhanced communication and relationships among city hospitals and medical groups. San Francisco General Hospital’s participation with SFMS historically has been lower than that of other hospitals—this is a timely opportunity to increase SFGH representation and involvement with SFMS.

SFMS/CMA Committees or Offices

Additional Relevant Experience

Why Are You Interested in Serving?

www.sfms.org

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CANDIDATE BIOGRAPHIES Board of Directors Ryan Padrez, MD Incumbent Director

Pediatrics

Adam schickedanz, MD

Rachel HuiChung Shu, MD

Incumbent Director

Incumbent Director

Pediatrics

Ob-Gyn

Current Job Positions and Hospital and Teaching Affiliations

I Pediatric Resident at the University of California, San Francisco, which serves as house staff for UCSF Benioff Children’s Hospital, San Francisco General Hospital, and Kaiser San Francisco hospital. Beginning in 2014, I will serve as one of the Pediatric Chief Residents at San Francisco General Hospital.

Chief Resident, Department of Pediatrics, University of California, San Francisco

Private Group practice; Managing Partner, SF Women’s Health Care, CPMC- OBGYN staff; Department OBGYN Med Exec committee member, 1998 to 2012; Clinical Faculty for UCSF and Dartmouth medical school; New Technology Committee Member, CPMC, 1998 to present; Perinatal Quality Assurance Committee Member, CPMC, 1996 to present; Credential Committee Member, Chinese Hospital, 1994 to present; Chinese Hospital Medical Executive Committee, 2001 to 2008

SFMS Board Member (2012-present), SFMS Executive Committee Member (2012-present), SFMS Delegate to the CMA House of Delegates (2011-present)

SFMS Board of Directors, 2011-13; Credentials Committee, 1994-2007; Alternate Delegate to CMA House, 2001-09; Nominating Committee Member, 2001-2003

Fellow of Science and Technology Policy at the Institute of Medicine, National Academies of Science in Washington, D.C. (2008-2009)

Chinese Hospital Community Health Plan Board of Trustee, 2008 to present; CCHCA Pharmacy committee member, 2000 to present. The other relevant experience is that we are now at a crossroad in health care, facing pressures from all sides to regulate our industry. I have lived through many changes in the last few years as the managing partner of my small group practice, and those changes impact our group as we go through the recession, implementing EMRs both in office and in the hospitals, and being able to attest for the HITECH meaningful use.

Connecting with the next generation of physicians is how the future of the Medical Society and the CMA will be built. I am committed to bringing the creativity, energy, and industry of young physicians to the Medical Society to start building that future now.

Over the next several years, with the Affordable Care Act being implemented, it will be very interesting as the parties maneuver to cover the added patients who join available health plans.

I feel that with my experience as a solo/small group provider in San Francisco for the past twenty years, I will give the board an added perspective regarding what we will be facing in the next few years from the private practitioner’s point of view. I feel that I speak for the solo and small group private practice providers and I would like to be at the table and in the conversation as the future unfolds.

SFMS/CMA Committees or Offices

SFMS Board of Directors, SFMS Membership Committee Member, SFMS PAC Board Member Additional Relevant Experience

Prior to medical school, I worked for five years in health policy in Washington, D.C. The majority of that time was spent in health care consulting for clients in government, life sciences, and nonprofits on topics related to Medicare and Medicaid. In medical school I then served as the voting student delegate to AMA, CMA, SFMS, and then to the AAMC. I currently serve as one of the UCSF resident delegates to the American Academy of Pediatrics.

Why Are You Interested in Serving?

After years of working in health policy, I am a believer in the need to better align physician voices for important policy issues affecting our practices and patients. This is especially true today, as changes from the Affordable Care Act begin to be implemented; never before has there been a greater need for physician advocacy. I see continuing to serve on the SFMS Board as a great opportunity to be a young physician helping SFMS fulfill this mission. Additionally, it is a privilege to help lead SFMS to become a relevant and thriving organization for today’s newest physicians in San Francisco.

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San Francisco Medicine October 2013

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SFMS Nominations Committee Paul J. Turek, MD

Urology and Men’s Health

James L. Chen, MD

Orthopaedic Surgery/Sports Medicine

Patricia J. Galamba, MD

Family Medicine

Current Job Positions and Hospital and Teaching Affiliations

Orthopaedic Surgeon, private practice with privileges at CPMC, St. Mary’s, St. Francis, and Chinese Hospitals

Currently in 27th year of solo private practice in SF; recent past Chief of Staff at Saint Francis Memorial Hospital, 2009-2013; Member, Board of Trustees, 2001-2009; Medical Director Palliative Services, 2004-current (implemented program)

None

Medical Staff Liaison to Saint Francis Memorial Hospital 2013

As board member and president of the American Society of Andrology, a 700-member international academic society, I oversaw the creation of a strategic plan, guided it into financially solvency, increased membership, and oversaw the merger of two international journals. As president-elect of the Society of Male Reproduction and Urology, an international society of clinicians, I implemented a successful social media campaign to increase the relevance of, and interest in, the field among next-generation clinicians.

I currently serve on the Finance & Policy subcommittee of the Asian Physician Advisory Committee at St. Mary’s. I have served on the Admissions committee for the U.C. Davis School of Medicine and the University of Hawaii Orthopaedic Residency.

Many years of activity within the medical community at CPMC and Saint Francis hospitals

I am committed to the welfare of doctors in today’s health care industry. Issues of technology as well as access to and cost of health care are well supported by various political agendas. The underserved and underrepresented majority, however, are doctors, and I am here to serve their unspoken and unmet needs.

I am interested in serving on the Nominations Committee to recruit new and diverse leaders for the medical community in San Francisco.

I enjoy meeting and connecting with physicians across the city and therefore appreciate the opportunity to serve.

I am interested in the ongoing function of the Medical Society and in supporting other physicians who want to participate in governance.

Director, the Turek Clinic, San Francisco and Los Angeles; Founding Board Member and Chair, Medical Advisory Committee, Clinic by the Bay; Former Endowed Chair Professor in Residence, UCSF Departments of Urology, OBGyn and Reproductive Sciences

SFMS/CMA Committees or Offices

None

Additional Relevant Experience

Why Are You Interested in Serving?

www.sfms.org

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CANDIDATE BIOGRAPHIES SFMS Nominations Committee Zuoqin (zoe) Tang, MD

Vanessa E. Kenyon, MD

Otolaryngology

Head & Neck Surgery

Pathology

Amy E. Whittle, MD

Pediatrics

Current Job Positions and Hospital and Teaching Affiliations

Partner, San Francisco Ear, Nose & Throat Medical Group. I have been a part of SFENT for four years, since completing my residency training at Stanford University Medical Center. I am affiliated with California Pacific Medical Center.

I am currently working as a hematopathologist for Kaiserâ&#x20AC;&#x2122;s regional consultation service in San Francisco.

Assistant Clinical Professor of Pediatrics, University of California, San Francisco; Medical Director, San Francisco Medical-Legal Partnership, San Francisco General Hospital; Course Director, Physician in Community & Behavior and Development rotations, UCSF Pediatric Residency

None

None

None

I have served as State Governmental Affairs Committee Representative for Chapter 1 of the California American Academy of Pediatrics for the past two years. We review state legislation relevant to pediatrics and choose areas on which to focus our advocacy efforts.

This is my first time serving in any medical society. I am interested in learning more about the medical communities in San Francisco and helping the organization.

I would like to serve as a bridge between physicians who are active in the community and the SFMS. My advocacy work for AAP-CA, the medical-legal partnership, and as director of the community medicine rotation at UCSF has provided me the opportunity to build a strong network of physician advocates and leaders.

SFMS/CMA Committees or Offices

None

Additional Relevant Experience

I have been a member of the Brown & Toland Credentialing Committee for three years, working with administrators and physicians from various specialties, reviewing applications for those interested in becoming Brown & Toland providers.

Why Are You Interested in Serving?

San Francisco has an incredibly diverse, dynamic medical community, of which Iâ&#x20AC;&#x2122;m honored to be a part. I wish to draw upon my relationships in our community to identify future leaders for the SFMS and therefore further promote the representation of all our providers.

30 San 31 SanFrancisco FranciscoMedicine Medicine October October2013 2013

www.sfms.org

AMA Delegate Robert J. Margolin, MD Incumbent Alternate

AMA Alternate Delegate

Young Physicians Section Delegate to the CMA House

Gordon fung, md, phd

Stephanie oltmann, MD

ALSO CANDIDATE FOR EDITOR

Incumbent Alternate

Family Medicine

Internal Medicine and Geriatrics Current Job Job Positions Positions and and Hospital Hospital and and Teaching Teaching Affiliations Affiliations Current

Primary Care Practice in Internal Medicine; Chief, Division of Internal Medicine at CPMC; Officer of the Medical Staff at CPMC; Board of Directors, Medical Insurance Exchange of California; Associate Clinical Professor, UCSF

See bio under Editor.

Adult Primary Care Physician at Dignity Health Foundation Group, St Maryâ&#x20AC;&#x2122;s Medical Center, and USF Student Health Center

SFMS/CMA Committees Committees or or Offices Offices SFMS/CMA

Alternate Delegate to the House of Delegates; CMA: Board of Trustees, Chair of the Audit Committee, Vice Chair of CALPAC; SFMS: Past President, Past Chair of the Delegation

None

Additional Additional Relevant Relevant Experience Experience

I have spent much of the past 20 years in leadership roles in our medical society and the CMA.

I have served as Co- Chief and Chief in my residency program at North Shore - LIJ Health System, Glen Cove, NY, and in that capacity I attended the Congress of Delegates for the NY State Academy of Family Physicians during my second and third year of residency.

Why Why Are Are You You Interested Interested in In Serving?

Serving?

I have greatly enjoyed my role as your AMA delegate for the past six years. I believe I have the experience, perspective, energy, and desire to continue to advocate for physicians and their patients and thus ask that you elect me to serve as your AMA delegate.

www.sfms.org

I am interested to serve in this position because I believe this would be a wonderful opportunity to broaden my horizons, to look beyond the daily practice of medicine, learn about the greater picture of health care, and get more involved in health policy.

October 2013 San Francisco Medicine

31

CANDIDATE BIOGRAPHIES Delegates to the California Medical Association House of Delegates Ameena T. Ahmed, MD, MPH

Brittany Blockman, MD

George Fouras, MD Incumbent Delegate

Internal and Preventive Medicine

Pediatrics

Child and Adolescent Psychiatry

Current Job Positions and Hospital and Teaching Affiliations

Psychiatry Consultant, Human Services Agency; Staff Psychiatrist, Special Programs for Youth/Juvenile Justice Center/Dept. of Public Health, City and County of San Francisco

SFMS/CMA Committees or Offices

University of California, San Francisco, Department of Pediatrics, PGY-2 Resident in Pediatric Leadership for the Underserved program; Director/Founder of Communitas, a support and education program for adolescents living with chronic illness and their parents

Board Member, SFMS PAC

SFMS member

SFMS Consultant to Board, 2013; Immediate Past President, 2012; President, 2011; PresidentElect, 2010; Secretary, 2009; Director, 2003-08; Executive Committee, 2003-11; SFMS PAC, 200413 (Chair 2007-08); Physician Membership Services, 2003-13; CMA Delegate, 2010-13; CMA Alternate Delegate, 2007-09/2000-02

Prior to medical school, I received a master’s in medical anthropology from Harvard University, focusing on the intersection of illness and society at large, and I worked as a documentary filmmaker with the goal of affecting policy through film. During medical school, I served in numerous leadership roles: Development Director of a community clinic, Curriculum Committee delegate, Founder of a support group for Alzheimer’s caretakers, chosen presenter for AAMC visit and regional Family Medicine Grand Rounds.

Past President, NC Regional Organization of Child and Adolescent Psychiatry; Co-chair, Adoption and Foster Care Committee for the American Academy of Child and Adolescent Psychiatry

I believe we have a responsibility to advocate for issues that are important to our patients’ well-being and to our lives as physicians. Being a delegate would allow me to continue my passion for social and political engagement within the medical community and help to bring positive change to medicine.

The SFMS delegation has been one of the most influential groups. It has been an honor to participate and to encourage younger physicians to become engaged in organized medicine. I hope that you will allow me to continue to serve the SFMS in the future. Thank you for your support.

Adult Medicine, Kaiser Permanente San Francisco Medical Center; Chief of Complementary and Alternative Medicine; Assistant Clinical Professor, Department of Epidemiology and Biostatistics, UCSF

Additional Relevant Experience

I completed a fellowship in social epidemiology, through which I developed a keen interest in how political and social factors affect health. This background has demonstrated to me how important policy is in shaping health and health care. I’ve had the privilege to volunteer with Physicians for Human Rights in Central Asia, the Middle East, and South America, working to end human rights abuses and create mechanisms for accountability.

Why Are You Interested in Serving?

I look forward to serving San Francisco’s physicians as a leader and advocate. I would be honored to work with my colleagues to shape policy to improve health in San Francisco.

32 33

San Francisco Medicine October 2013

www.sfms.org

Katherine E. Herz, MD

Edward T. Melkun, MD

David R. Pating, MD

Incumbent Alternate

Dermatology

Plastic Surgery

Psychiatry and Addiction Medicine

CurrentJob JobPositions Positionsand andHospital Hospitaland andTeaching TeachingAffiliations Affiliations Current

The Permanente Medical Group, Kaiser San Francisco, Department of Pediatrics

Founder, Melkun Plastic Surgery; hospital affiliations include Saint Francis Memorial Hospital, CPMC-St. Luke’s Hospital, and Kaiser Permanente Hospitals (Oakland and Hayward)

Chief, Addiction Medicine, Kaiser San Francisco Medical Center; Regional Chair, Addiction Medicine Chiefs, Kaiser Northern California; Assistant Clinical Professor, UCSF; Fellowship Site Director-Addiction Psychiatry

SFMS Board Director, Executive Committee, PAC Vice Chair, Physician Membership Committee

CMA, Committee on the Medical Board (2009), Marijuana Regulation TAC (2011), CMA Gary Nye Award for Physician Health and Well-Being (2011); SFMS, Psychiatry Committee (consultant), SFMS Journal Guest Editor and Contributor, SFMS Daniel Perlman Journalism Award (2011)

John Troxel legislative fellow in Sacramento on behalf of California Society of Plastic Surgeons, Madera Del Presidio Home Owners’ Association Board, prior executive experience within college fraternity

Advisor, San Francisco Department of Public Health (Healthy San Francisco Program, Mental Health Services Act, and Suicide Prevention Taskforce); State Commissioner, California Mental Health Oversight and Accountability Commission (Prop. 63); Chair, California Coalition on Whole Health (MH/SUD coalition on implementation of CA Health Exchange); Board Memberships: CHA-Behavioral Health Board, CPA-Government Affairs, CSAM/ASAMExecutive Councils, CPPPH-Board, National Quality Forum-Behavioral Health Committee; Past Advisor to Medical Board of California, Diversion Program

As an independent specialist in private practice, I have seen dramatic changes to the practice of medicine. I see every change to reimbursement and every regulation firsthand and am very sensitive to how they affect the bottom line. Physicians need to aggressively demand positive changes.

I wish to “give back” to SFMS by participating in its vibrantly influential leadership in health policy. Whether through its far-reaching journal, SFDPH collaborations, or progressive CMA resolutions promoting reform in health care, SFMS is a winner. I hope to make a humbly significant contribution to the SFMS agenda.

SFMS/CMA SFMS/CMACommittees Committeesor orOffices Offices

Alternate Delegate, CMA House of Delegates, 2012-2013

AdditionalRelevant RelevantExperience Experience Additional

I have studied health economics and health policy both as an undergraduate and following residency during a fellowship at Stanford, where I earned a master of science in health services research. This background has provided me an in-depth education in the complexities of health care delivery and how policy can affect our work as physicians.

WhyAre AreYou YouInterested InterestedIn in Serving?

Serving?

Why

I enjoy both clinical medicine and population-based interventions that influence health. I would be honored to serve as a delegate to the CMA House of Delegates, where I believe we have many opportunities to help shape both debate and policy around health care.

www.sfms.org

October 2013 San Francisco Medicine

33

CANDIDATE BIOGRAPHIES Delegates to the California Medical Association House of Delegates tristan sands, md, phd

Brigitte watkins, md

Judy L. Silverman, MD Incumbent Alternate

Pediatric Neurology

Physical Medicine, Rehabilitation, and Pain Medicine

Family Medicine

Current Job Positions and Hospital and Teaching Affiliations

Child Neurology Fellow, University of California San Francisco

Private practice, St. Mary’s Spine Center

Second Year Resident Physician, UCSF/SFGH Family and Community Medicine Residency Program

Alternate delegate to CMA, 2010-2011

None

I approach patient care from a multidisciplinary perspective, integrating psychological and social issues with the medical condition.

At the CMA House of Delegates, this ability to integrate allows me to help develop policy that unites the concerns of physicians and patients. I feel my perspective as a physiatrist allows me to advance the goals of the CMA.

As a physician in primary care, I’d like to take a more active role in advocating for my patients and for advancing the delivery of primary care. I’m particularly interested in learning more about, and contributing to, CMA resolutions relevant to the care of medically underserved populations.

SFMS/CMA Committees or Offices

I have not yet served in the San Francisco Medical Society, and this represents my first foray into active participation in a professional medical organization.

Additional Relevant Experience

As a resident in pediatrics and neurology and now as a child neurology fellow, I have come to know the critical role of physicians in advocating for those who cannot advocate for themselves, and this has fed a burgeoning interest in policy and its creation.

Why Are You Interested in Serving?

Medicine is as much a calling to service as a career choice. Our role as educators and advocates extends beyond our individual patients to a more general societal commitment for care. Physicians and patients must have a voice in the changing health care environment.

34 35

San Francisco Medicine October 2013

www.sfms.org

ELIzABETH K. zIEMANN, MD

RICHARD A. PODOLIN, MD, FACC

KEITH LORING, MD

ALSO CANDIDATE FOR SECRETARY

ALSO CANDIDATE FOR BOARD OF DIRECTORS

Incumbent Alternate, Incumbent Director

Family Medicine Current Job and Affiliations

Family Physician, Physician Foundation Medical Associates/Sutter Pacific Medical Foundation, August 2010-present; hospital affiliation at CPMC/St. Luke’s; Epic EHR Power User, Sutter Pacific Medical Foundation; Epic EHR Implementation Expert, Sutter Pacific Medical Foundation/CPMC; Volunteer Faculty, Sonoma State University, Family Nurse Practitioner Program

SFMS/CMA Committees or Offices

Why Are You Interested In in Serving?

See bio under Secretary.

See bio under Board of Directors.

In this period of fundamental change in our health care system, physicians need an advocate and a partner. As a delegate to the CMA from the California Chapter of the ACC, I learned that the activities of the CMA directly affect the viability of medical practice in this state.

SFMS, Board of Directors; SFMS, Liaison to CPMC/St. Luke’s Hospital; SFMS, Nominations Committee

Breathe Again !!

Additional Relevant Experience

CALIFORNIA SINUS CENTERS & Institute

California Health Care Leadership Academy (recipient of SFMS scholarship); American Academy of Family Physicians (AAFP), Chief Resident, Leadership Development Program

We CARE for: Bacterial Infections / Sinusitis Culture directed treatment Functional Endoscopic Sinus Surgery Orbital Decompression / Graves’ Disease Image Guided Surgical Navigation Revision - complex cases Frontal Sinusitis Advanced Endoscopic Techniques Sinuplasty Sinus Surgery WITHOUT packing Nasal Obstruction / Septoplasty Allergic Fungal Sinusitis Sinonasal Tumors / Polyps Smell / Taste problems CSF leak repairs Mucoceles / Abscesses In-Office CT Scanner Urgent appointments Joint care: ENT - Allergy Pulmonary

Why Are You Interested in Serving?

I am interested in this position because I want to learn how to effectively engage in the legislative process. I believe primary care physicians have a unique and vital perspective on health care and need to be leaders in health care reform. I have been mentored by several other board members who have encouraged me to participate in the delegation and I very much would like to serve our medical community and the society in this way.

Atherton (Stanford area) Walnut Creek (East Bay) San Francisco (Union Square) Winston Vaughan, MD Karen Fong, MD

www.sfms.org

Kathleen Low, NP

Sherry Derakhshandeh, MD

Sacramento

www.CalSinus.com october 2013 San FranciSco Medicine

35

MEDICAL COMMUNITY NEWS KAISER

SFVAMC

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Kaiser Permanente, since the 1950s, has been exploring the benefits of using information technology to improve the care that its health care professionals provide their patients.

While the pace of innovation and the creation of easily used tools took a few decades to become widely accessible, the intent to manage patient care in the most efficient and effective way possible has always been the motivation. Locally, at the San Francisco Medical Center, providers having been using an inpatient and outpatient electronic medical record, known familiarly as KP HealthConnect, for more than seven years.

This groundbreaking health care tool enables providers to call up clinical data in a matter of minutes, schedule labs and tests, identify needed preventive screenings (e.g., Pap smears, mammograms, colonoscopies), and coordinate care across specialties. The database available to KP HealthConnect users is rivaled only by the one used by the Veterans Administration.

Chronic disease management, a cornerstone of the recent federal Health Care Reform Act and a central component of clinical practice at Kaiser Permanente, is enhanced, because providers can easily identify a patient’s disease status, control medications, and suggest behavior adjustments. As the database for individual records grows, it becomes possible to manage entire populations with a specific condition, as research provides compelling evidence as to effective treatments. All the data is shared throughout the Kaiser Permanente system through the electronic medical record. For providers, day-to-day clinical care becomes more effective, as information is readily available for medication refills, preventive care screenings, and electronic prompts that indicate when improvements in care and follow-up appointments are necessary. One highly successful initiative that has been made possible by the use of electronic health care tools is the “I Saved a Life Program,” which enables a medical assistant to book same-day mammogram appointments for patients. This has led to identifying several cancers and ultimately saving lives. The medical assistants have been acknowledged for their critical role in saving these patients’ lives.

36 37

Researchers at the San Francisco Veterans Affairs Medical Center (SFVAMC) have used the central database of all VA patients to perform groundbreaking research that improves medical care. The VA has one national electronic medical record (EMR) that covers about 8 million veterans cared for at 153 medical centers, 800 clinics, and 135 nursing homes by 180,000 providers and 57,000 trainees. All data are swept into a deidentified central database that researchers use. There is complete access to all laboratory values, vital signs, medications with renewal frequency, allergies, drug reactions, procedures codes, ECG reports, pathology codes, and diagnoses. Specialized searches can find key text words in all notes and reports, as well as visualize radiological studies.

Using this database, SFVAMC researchers were the first to show that posttraumatic stress disorder (PTSD) was accompanied by increased medical morbidity. Kristine Yaffe showed that PTSD led to increased dementia.

Karen Seal demonstrated for the first time the high rate of mental illness as well as PTSD in returning veterans from the Iraq and Afghanistan wars. To address these issues, Rina Shah and Karen Seal established primary care clinics that integrate mental health care into primary care medicine, avoiding the stigma of a mental health clinic.

Barry Massie demonstrated that putting clinical reminders in the VA EMR triggered by results of echocardiography improved therapy for congestive heart failure. Michael Shlipak and Carl Grunfeld used the VA database to definitively demonstrate the risk of kidney disease induced by the HIV antiretroviral drug tenofovir. They also defined the factors in HIV infection that lead to increased heart disease and renal failure.

The 262 principal investigators and 965 researchers of the SF-VAMC are committed to using the unparalleled resources of the VA to improve health care for our veterans and for all patients worldwide.

San Francisco Medicine October 2013

St. Francis Robert Harvey, MD

For my first column as the Saint Francis Chief of Staff, I’d like to touch upon the many improvements our hospital has made in the area of radiology and mammography, and the incredible benefits this will have to our ability to care for patients. But first, I’d like to congratulate our former Chief of Staff, Dr. Patricia Galamba. She has dedicated many years of service to Saint Francis in various capacities and has provided fantastic direction as the Chief of the Saint Francis medical community for the last four years, and I appreciate her support as I transition to this new role.

In the past two years, our hospital has been fortunate to receive the tremendous support of the Saint Francis Foundation, the medical staff and patients, who all have contributed to the upgrade of our Digital Imaging Services. As a result, beginning in June we began performing procedures on our new Hologic Digital Mammography System, which provides high-quality digitized images that use the most advanced software and analytics.

These upgrades dovetail with other recent improvements, such as the installation of a new CT and MRI scanner. In May, we began using this new equipment, which is a high-speed, low-radiation dose system that provides what is considered the thinnest slice reconstruction hardware in the industry. The scanner has the Vitrea Image Management System that allows for 2, 3 and 4-D reconstruction and visualizing the anatomy in multiple views.

And that’s not all. We’re about to kick off Phase 3 of this project, which includes the construction of the suite that will house the Titan 3T MRI System. This technology allows Saint Francis to set new standards for imaging and productivity while providing unparalleled comfort to our patients.

None of these enhanced services would be possible without the support for our administration, the Saint Francis Foundation and the many donors that helped fund this endeavor. We are all very thankful of the support this project has received. www.sfms.org

CPMC Michael Rokeach, MD

CPMC ranks among the best hospitals in the San Francisco/Oakland metropolitan area and in California, according to the U.S. News and World Report ranking of America’s Best Hospitals. The annual survey uses a set of criteria to identify the most distinguished hospitals that make up its list. In California, CPMC is positioned in the top 10 percent, with a rank of 37 out of 440 hospitals statewide. In the San Francisco/Oakland metropolitan area, CPMC reached a ranking of 5 out of 47 hospitals and has the distinction of being ranked second in the City of San Francisco. CPMC was also recognized for high-performing specialties in neurology/neurosurgery and in orthopedics. The Sutter Health Endpoint Encryption Project was selected as the ISE® West Project of the Year by T.E.N., a technology and information security executive networking and relationship-marketing firm. Finalists and winners were honored at the 2013 ISE West Executive Forum and Awards Gala, held in August at the Westin St. Francis in San Francisco.

Jeff Trudeau, information security officer for Sutter Health, accepted on behalf of the project, which implemented a FIPS 140-2-certified, centrally managed encryption solution to all endpoint devices and their USB ports in order to protect confidential information in the event of a device being lost or stolen. The ISE West awards recognize both information security executives and projects for outstanding achievements in risk management, data asset protection, compliance, privacy, and network security. CPMC has been recognized as a “Leader in LGBT Healthcare Equality” in the Healthcare Equality Index 2013, an annual survey conducted by the Human Rights Campaign (HRC) Foundation, the educational arm of the country’s largest lesbian, gay, bisexual, and transgender (LGBT) organization. CPMC earned top marks for its commitment to equitable, inclusive care for LGBT patients and their families, who can face significant challenges in securing adequate health care. Facilities awarded this title meet key criteria for equitable care, including nondiscrimination policies for LGBT patients and employees. www.sfms.org

Brown & Toland Neal Birnbaum, MD

Brown & Toland’s board of directors made the decision many years ago to invest in a comprehensive set of technology tools to clinically integrate our network of independent physicians to help improve quality and reduce costs. A key component of that tool set, an interoperable electronic health record, was first deployed to our physicians in 2005.

Additionally, our technology plan included building interfaces between our doctors and the disparate systems of our hospital and ancillary care partners, to improve the flow of information. Today, more than 260 of our busiest physicians use the electronic health record. Over the years, health information and test and lab results for hundreds of thousands of patients have been fed into the system, creating a data repository of health care information that today holds more than 125,000,000 pieces of clinical information.

In many respects, Brown & Toland has built a health information exchange (HIE).

This exchange allows us to bring the benefits of clinical integration to all our physicians’ patients, regardless of the type of insurance they hold, and it gives us the data to use predictive analytics to help us develop the right health management programs for our physicians and care management team.

Additionally, our health information exchange helps prevent duplicate test orders and medication errors. Our doctors work together to coordinate care, which results in a better patient experience and better health outcomes. The HIE also gives our organization the ability to participate in a number of accountable care and other innovative initiatives.

Sutter Pacific Medical Foundation Bill Black, MD, PhD

Sixteen years ago, I was one of the first physicians at Sutter Health’s Palo Alto Medical Foundation to implement the electronic health record (EHR). We were mostly focused on how an EHR could provide identity-authenticated access to a patient’s chart in multiple locations, and on electronic integration of test results. The real big data utility of an EHR—aggregation and integration of the vast quantities and diversity of our patients’ data, analyses of population health, identification of care-customization opportunities, the automation of routine care management tasks, and measuring and reporting outcomes for care and process improvement—was still to come. I recently checked in with some Sutter Pacific Medical Foundation (SPMF) big-data experts on where we are.

Deborah Wyatt, MD, SPMF EHR Physician Champion, reminded me, “Big data refers not to the megabytes that medical information holds but rather to the effect it will have on the health care provided to individuals and populations. The ability to identify populations at risk for certain diseases, to capture an individual who requires specific vaccines, to further scientific research are only a few examples. Mining big data has and will continue to transform the practice of medicine.”

Kathy Horan, MD, SPMF director of Medical Informatics, pointed out that big data has an immediate point of care benefit. “Having the health maintenance items readily available within the Sutter EHR has been a great benefit to clinicians and patients. We can be more proactive in requesting appropriate screening care, which leads to better teamwork between the clinicians and patients.”

The 2001 Institute of Medicine’s Quality Chasm report suggested our goals ought to be clinical care that is safe, effective, patientcentered, timely, efficient, and equitable. Sutter’s EHR gets us closer to those goals for our communities and patients.

October 2013 San Francisco Medicine

37

MEDICAL COMMUNITY NEWS St. Mary’s Robert Weber, MD

I was fortunate enough to attend the San Francisco 49ers game on October 6. I was even more fortunate they beat the Houston Texans fairly resoundingly by a final score of 34-3.

So what does this have to do with our theme of this month’s magazine you ask? Well, it happened to be the night of a breast cancer awareness game. Everyone was adorned with pink accoutrements – pink shoes, pink towels, even pink flags from the referees. I really wondered what the impact would be on that huge bunch of loud football fans.

Luckily, I got my answer. During a timeout, survivors were brought onto the field to be honored by fans. I was struck during the ceremony by the fact that I have heard since my training that 1 in 8 women will get breast cancer.

That is a lot of women. These days as I age I value my friends more and more, and I realize how many people I know have had or will get breast cancer.

It is easy for me as the Chief of Staff at St. Mary’s Medical Center and a medical oncologist to help the hospital shape the delivery of the product when it comes to cancer care delivery. We have excellent surgeons, state of the art imaging, world renowned pathology, my favorite breast cancer nurse navigator and brand new radiation therapy equipment.

This all allows us to provide excellent care to our patients at the Dignity Health Cancer Center. But what it does not do is change the rate, that 1 in 8 number.

My hope is that rather than creating fear in a patient when they are given a dreaded cancer diagnosis, we can comfort ourselves with the understanding that medically we are doing everything we can to provide the best care possible.

38

IN MEMORIAM

Nancy Thomson, MD

Blaine Scott Boyden, MD Dr. Boyden died on November 6, 2012, at the age of 83 at his home surrounded by his family. Born on May 7th, 1929 on the island of Kauai, he was the son of Dr. A. Webster Boyden and Eleanor Scott Boyden, and younger brother to Richard Boyden. He attended Case Western University for medical training and was an Ophthalmologist in San Francisco and member of the SFMS since 1962. Blaine is survived by his wife of 51 years, Nancy Cusack Boyden, their four children, Patty Boyden Patsel of Corte Madera, CA; B. Scott Boyden Jr. of Raleigh, NC; Tom Boyden of Corte Madera, CA; Mike Boyden of San Francisco, CA, along with eleven grandchildren.

Philip Carleton Bartlett, MD

Dr. Phil Bartlett passed away peacefully at his home in Tiburon on June 13, 2012. Phil was born in Seattle and grew up in Berkeley, then Orinda. He was in the first class at Miramonte high school but spent most of his time working on cars so he transferred to Robert Louis Stevenson School in Pebble Beach which propelled him to his beloved Stanford University and then Tulane Medical School. After an internship in New Orleans, Phil served his country in Vietnam in the US Air Force where he became a trusted physician and surgeon to locals and American troops. He returned to the US in 1970, retrieved his family from Miami and drove across our country in a VW Bug to buy the first family home in West Portal with Vietnam poker proceeds and began his residency at UCSF. Dr. Bartlett served San Francisco for forty years as a highly respected adult and pediatric otolaryngologist. Dr. Bartlett’s patients loved his smile, bow ties, calm yet confident demeanor and results. Phil loved his family, being outdoors, roses, cars, Mozart and Stanford Football.

Childhood in the Trinity Alps and college summers with the US Forest Service in Tahoe lead to years of family camping, river rafting, hiking and skiing. He was a member of The Guardsmen and the Bohemian Club.

He is survived by his wife Pamela, their two children, three older sons and eight grand-children.

Louis Vuksnick, MD

A gifted and beloved psychiatrist and Jungian analyst, Louis Martin Vuksinick, MD, (Lou) died nobly as he had lived, on Wednesday, October 17, 2012, at home after challenging leukemia and throat cancer for four years. During this time he continued to practice in San Francisco and in Palo Alto where he lived.

He is survived by his wife of thirty years, Janet Robinson, the love of his life; four stepchildren; Gregory, Timothy, Anne and Jeffrey Petersen and their partners and seven grandsons; and his sister Maxine Russell of Salt lake City. Born in Spring Glen, Utah, February 27,1934 to Louis L. Vuksinick and Zelpha Skriner, he attended medical school at the University of Utah. Coming to San Francisco in 1959 for his internship at St. Mary’s Hospital, he went on to complete his psychiatric residency at Stanford University Medical School 1960-63 and Analytic Training at the C. G. Jung Institute of San Francisco 1974-88. He held leadership and teaching roles in the Department of Psychiatry, McAuley Neurospsychiatric Institute, St. Mary’s Hospital 1969-1980. He is noted for his work about the body-psyche connection, and his love of music, especially opera. He will be greatly missed.

Kevin D. Harrington, MD

A passionate defender of the undefended and a true Renaissance Man with interests in music, art and books, Dr. Harrington died on January 7, 2013, in the presence of his wife, Peggy at their Mill Valley Home. A San Francisco native, born on November 30, 1938, Dr. Harrington graduated from Yale University and UCSF Medical School. He interned at the Hospital of the University of Pennsylvania in 1965, served three years in the Army, and did an orthopedic residency at UCSF. He was assistant chief of orthopedic surgery at San Francisco County Hospital from 1972 to 1977 before entering private practice in San Francisco. He had numerous Visiting Professorships throughout the United States, Europe and South America. He held numerous academic appointments, authored more than a hundred papers on orthopedics and presented at professional meetings worldwide and authored a book on the Orthopaedic Management of Metastatic Bone Disease. Kevin Harrington epitomized his dedication to the Hippocratic Oath and gave unstintingly of his time and expertise. He volunteered at the Albert Schweitzer Hospital in Haiti and at the “Hole in the Wall Gang” camp in Connecticut, and finally after retiring from private practice in 2003, Dr. Harrington committed his time, talent, and great enthusiasm to the Marin Community Clinics, where he spearheaded and expanded orthopedic services to the underserved of Marin County. Kevin Harrington was married to Margaret (Peggy) Harrington, also an MD, for thirty-two years and is survived by his and her five children, his grandchildren, his sister, and their extended family. the underserved of Marin County. Kevin Harrington was married to Margaret (Peggy) Harrington, also an MD, for thirty-two years and is survived by their five children, grandchildren, a sister, and extended family.

San Francisco Medicine October 2013

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