September 2016

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

DILEMMAS IN THE

DIGITAL AGE

QUALITY, CONFUSION, HYPE, AND HOPE

The Digital Doctor

Big Data, Big Mistakes?

Quality Contradictions

Health IT

Disruptive for Better - or Worse?

Plus:

That Lethal Bridge Rotten Reproductive Politics Laguna Honda: 150 Years Old VOL.89 NO.7 September 2016

MIEC Belongs to Our Policyholders!

Toni Brayer, MD Board of Governors

Over the last 20 years California policyholders have saved an average of 25% on premiums due to our Dividend Program*

Keeping true to our mission MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For over 40 years, MIEC has been steadfast in our protection of California physicians with conscientious Underwriting, excellent Claims California Dividends as % of premiums management and hands-on Loss Prevention ($1m/$3m limits) services; we’ve partnered with policyholders 60% to keep premiums low.

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

September 2016 Volume 89, Number 7

Quality in Medicine FEATURE ARTICLES

LETTER FROM THE UNITED STATES SURGEON GENERAL

8

Dear Colleague: I am asking for your help to solve an urgent health crisis facing America: the opioid epidemic. Everywhere I travel, I see communities devastated by opioid overdoses. I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure.

It is important to recognize that we arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught—incorrectly—that opioids are not addictive when prescribed for legitimate pain.

The results have been devastating. Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly—almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed. Now, nearly two million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C. I know solving this problem will not be easy. We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic. As cynical as times may seem, the public still looks to our profession for hope during difficult moments. This is one of those times.

That is why I am asking you to pledge your commitment to turn the tide on the opioid crisis. Please take the pledge, located here: http://turnthetiderx.org/join. Together, we will build a national movement of clinicians to do three things: First, we will educate ourselves to treat pain safely and effectively. A good place to start is the pocket guide with the CDC Opioid Prescribing Guideline - http://turnthetiderx.org/treatment.

Second, we will screen our patients for opioid use disorder and provide or connect them with evidence-based treatment. Third, we can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing.

Years from now, I want us to look back and know that, in the face of a crisis that threatened our nation, it was our profession that stepped up and led the way. I know we can succeed because health care is more than an occupation to us. It is a calling rooted in empathy, science, and service to humanity. These values unite us. They remain our greatest strength.

Thank you for your leadership.

—Vivek H. Murthy, MD, MBA - August 2016

The Worst and Best of Times: Robert Wachter, MD, on Hope, Hype and Harm in Medicine's New Tech Era Steve Heilig, MPH

11 Healthcare Quality Measures: A Contradiction in Terms?

Michel Accad, MD

12 Big Data and Big Mistakes: Is Our Information Today Better

Or Is There Just More Of It?

Kevin R Stone, MD 13 Can’t Health IT Be Made Better? Disruptive Isn’t Always Productive

Art Papier, MD

15 Out of the Office: Tale of a Suicide, the End-of-Life “Option”

We All Deplore

John Maa, MD, FACS

17 Health Policy Perspective: Good Medicine And Bad Abortion

Politics Don't Mix

Pratima Gupta, MD and Steve Heilig, MPH

MONTHLY COLUMNS 4

Membership Matters

5

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President’s Message Richard Podolin, MD

21 Medical Community News 22 Upcoming Events

OF INTEREST 18 Ask the SFMS: Getting Ready for ICD-10: 2017 Style 20 One Hundred Fifty Years of Laguna Honda Editorial and Advertising Offices: 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfms.org

Take the Pledge: http://turnthetiderx.org/join Read the Guide: http://turnthetiderx.org/treatment

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

MACRA Resources To help physicians understand the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) payment reforms, and what they can do now to start preparing for the transition, the California Medical Association (CMA) has published a MACRA Resource Center. There you will find an overview of MACRA, and a comprehensive list of tools, resources and information from CMA, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services. CMA has also published a MACRA preparation checklist for physicians that contains specific actions practices should take as they prepare for the implementation of MACRA in 2017. The AMA has put together an action kit to help physicians prepare their practices for the transition to MACRA. CMA MACRA Resource Center – www.cmanet.org. AMA MACRA Action Kit – www.ama-assn.org/go/medicarepayment

Covered California Announces Offerings for 2017

Covered California, the state marketplace for health insurance under the Affordable Care Act, recently announced the qualified health plans that were approved to offer coverage in the exchange market for 2017. All of the plans that offered coverage in 2016 will continue to do so in 2017. In addition, Oscar (www.hioscar.com) is expanding its Exclusive Provider Organization (EPO) coverage into San Francisco (region four). For a complete listing of plans and product types offered by region, see the Covered California 2017 Plans Booklet (see page thirty-one) at www.coveredca.com.

“Yes on 56” Tobacco Tax Initiative (SFMS supports)

The California Healthcare, Research and Prevention Tobacco Tax Act of 2016 will increase California’s cigarette tax by two dollars per pack, with an equivalent increase on products containing nicotine derived from tobacco, including e-cigarettes. Nearly one million Californians have signed a petition to get this initiative on the November ballot. For more information, visit www.savelivesca.com.

San Francisco vs. Big Soda (SFMS supports)

A November 2016 Ballot Measure will tax distributors of sugar sweetened beverages a penny per ounce. These revenues can be used to support health education programs and efforts to improve children’s health across San Francisco. The soda tax was placed on the ballot by Supervisor Malia Cohen with the support of Supervisors Scott Wiener, Mark Farrell and Eric Mar. For more information, visit www.sfunitedtoreducediabetes.com.

Call for Medical Board Reviewers

The Medical Board of California is seeking physicians to serve as Expert Reviewers in disciplinary cases. Expert reviewers are needed in the following specialties: Addiction Medicine with additional certification in Family, Internal Medicine or Psychiatry; 4

Colon and Rectal Surgery; Dermatology; Family Medicine; Neurological Surgery; Neurology; Obstetrics and Gynecology; Pathology; Pain Medicine; Pediatric Cardiac Surgery; Pediatric Pulmonology; Plastic Surgery; Psychiatry; Surgery; Urology; and Vascular Surgery.

Physicians interested in serving as expert reviewers for their specialty can find out more information and apply at the Medical Board website (http://www.mbc.ca.gov/Enforcement/ Expert_Reviewer/). Participating physicians are reimbursed one hundred fifty dollars per hour for conducting case reviews and oral competency exams, two hundred dollars per hour for providing expert testimony, and usual and customary fees for physical or psychiatric exams. For more information about the Expert Reviewer Program, contact the Medical Board at (818) 551-2129.

Call for Primary Care Residency Reviewers

The Office of Statewide Health Planning and Development (OSHPD) is seeking members for a Subject Matter Expert (SME) Review Panel for the Song-Brown Primary Care Residency Program.

Learn more about the Song-Brown grant process by lending your expertise as a reviewer to score Song-Brown grant applications.

Song-Brown is currently accepting applications for Primary Care Residency reviewers. Join us as we continue to support access to safe, quality healthcare environments that meet California’s diverse and dynamic needs. If interested, apply at: http://www.oshpd. ca.gov/documents/hwdd/song-brown/2016/sme-applicationform.pdf and submit your résumé to Tyfany Frazier at: songbrown@ oshpd.ca.gov. Applications to serve as a reviewer are accepted on an ongoing basis.

Last Chance for Some Providers to Prevent Deactivation by Medicare

Noridian, Medicare’s administrative contractor for California, will soon begin deactivating billing privileges for physicians who received revalidation notices from Noridian but have not submitted completed applications to the Centers for Medicare and Medicaid Services (CMS). Since the passage of the Affordable Care Act (ACA), all Medicare providers and suppliers have been required to revalidate their Medicare enrollment information under new enrollment screening criteria in an effort to prevent fraud within the Medicare system. Once a Medicare enrollment application is validated, the clock starts ticking on a five-year revalidation cycle. Now that five years have passed since the ACA's revalidation requirement took effect, CMS has initiated a second cycle of revalidation requests.

Noridian will send revalidation notices two or three months prior to each provider’s revalidation due date. The first revalidation due date for this second cycle was May 31, 2016. Effective August 14, 2016, Noridian deactivated the Medicare billing privileges for affected physicians who failed to complete their revalidation applications CMS prior to the May deadline.

SAN FRANCISCO MEDICINE SEPTEMBER 2016 WWW.SFMS.ORG

The due date for the second revalidation round was June 30, 2016. Noridian will deactivate billing privileges for physicians who missed the June deadline on September 13, 2016. To prevent deactivation, you may look up revalidation dates through the CMS look-up tool (https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/MedicareProviderSupEnroll/Revalidations. html). If it shows that your practice missed the deadline, you should submit and sign your application online through the PECOS system immediately to prevent deactivation. If you are ultimately deactivated for failure to respond to a revalidation notice, you will be required to submit a reactivation application.

If your revalidation application is approved, no further action is needed. For more information on the revalidation process, see MLN Matters #SE1605 by visiting https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1605.pdf If you have questions about the revalidation process, contact Noridian at (855) 609-9960.

2017 Medicare Fee Schedule Released

CMS recently released the proposed 2017 Medicare Fee Schedule. Included in the payment rule is the long-awaited “California GPCI Fix.” The locality changes and payment updates will be phased-in from 2017 to 2022. CMA is reviewing the complex California GPCI implementation proposal and will provide additional information once that analysis is complete. Moreover, CMS made updates to the Geographic Practice Cost Index (GPCIs) nationwide based on new wage, rent, and malpractice expense data. CMA is also analyzing these changes for accuracy. CMS is improving Medicare payment for services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment or mobility-related disabilities. CMS is also expanding the Diabetes Prevention Program innovation center model.

New Online Medi-Cal Provider Enrollment Portal to Launch October 2016

The California Department of Health Care Services (DHCS) plans to launch its new Medi-Cal provider enrollment system in October. The Provider Application and Validation for Enrollment (PAVE) system will transform provider enrollment from a manual paper-based process to a web-based portal that providers can use to complete and submit their applications and verifications and to report changes. PAVE will improve the provider enrollment experience by minimizing errors, improving the application process, and significantly reducing the time required to process provider enrollments. For more information, visit www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx.

CMA’s Practice Management Tip of the Month

Make sure billing staff are aware of the prohibitions on balance billing Medi-Medi patients. Both state and federal law provide broad protections to such individuals, and prohibit billing a Medi-Cal patient in most circumstances.

Running afoul of these laws can put you at risk of a CMS audit and sanctions.

For more information on this topic, see “Ask the Expert: Billing Medi-Medi patients,” free to members at www.cmanet.org/ces.

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September 2016 Volume 89, Number 7 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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Success.

It’s what California’s finest physicians strive for... and what CAP can help you achieve.

Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand the realities of running a medical practice, and we are committed to supporting you with a range of valuable programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

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Violations, not only explains how to avoid such mistakes, but cites the accompanying penalties for these common – yet easily avoidable – violations.

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PRESIDENT’S MESSAGE Richard Podolin, MD

The Elusive Quest for "Quality" Countless quality reporting initiatives have been developed and innumerable hours spent in medical offices and hospitals in pursuit of quality improvement, so why have these efforts engendered so much frustration and such inconsistent demonstrable benefit? If the devil is always in the details, why is medical quality improvement so uniquely beset with demons?

The problems are real. Our expenditure on health care as a percentage of gross domestic product (greater than thirteen percent) is the highest in the world, and our per capita health care expenditure is third highest (after Switzerland and Norway). Yet there is no evidence that our outcomes are better. We rank forty-third in life expectancy. Forty-four countries have a lower infant mortality rate. Studies from the Dartmouth Institute for Health Policy and Clinical Practice have found a more than three-fold regional variation in Medicare spending per beneficiary without any corresponding difference in outcome. The primary driver of this variation is “supplysensitive care”—patients in regions with more hospital beds, more physicians, and more specialists receive more care, but not more effective care. In 1999, the Institute of Medicine released “To Err is Human: Building a Safer Health System,” claiming that up to ninety-eight thousand patients each year die in hospitals as the result of medical errors. A recent article revised that number up to two hundred fifty thousand, potentially making medical error the third largest cause of death in the nation.1 These numbers are controversial, but no one would deny the importance of reducing medical errors. Yet a study of ten North Carolina Hospitals showed no reduction in patient harm in the eight years following publication of “To Err is Human.”2 “Unexplained clinical variation” has been invoked as the major driver of uneven quality, spiraling healthcare cost, and patient harm.3 Proponents argue that if physicians routinely followed evidence-based best practices, patients would receive high quality care with less exposure to costly, less effective, and potentially harmful interventions. Best practices are not equivalent to less care. Some patients might receive more services, but because of their proven efficacy the result would be better outcomes and cost savings down the road. The Physician Quality Reporting System (PQRS) was an attempt to increase adherence to guidelines and reduce clinical variation.

The theory sounds reasonable, so why has success been so elusive? Even the most ardent proponents of evidence based medicine admit there is sound scientific evidence for less than twenty percent of the complex clinical decisions physicians are forced to make every day. Many clinical dilemmas are not scientific questions. An editorial in the New England Journal of Medicine about new guidelines for screening WWW.SFMS.ORG

mammography points out: “Scientific evidence can only help us describe the continuum of benefit versus harm. The assessment of whether the benefit is great enough to warrant the risk or harm – i.e., the decision of where the threshold for intervention should lie – is necessarily a value judgment.”4 Even when studies have demonstrated the effectiveness of certain “best practices,” the utility of these guidelines for improving outcomes in general clinical practice has a poor record. Studies of hip surgeries, asthma, diabetes and hypertension have all shown that compliance with Medicare quality metrics had no effect on outcomes. Other “best practices,” such as tight control of glucose in critically ill diabetic patients or the preoperative initiation of beta blockers in patients at risk for coronary artery disease, were actually associated with worse outcomes in subsequent studies. Dr. Jerome Groopman, professor of medicine at Harvard Medical School, attributes the repeated failures of “best practices” to improve outcomes to a conceptual error on the part of the expert panels responsible for their development: “They did not distinguish between medical practices that can be standardized and not significantly altered by the condition of the individual patient [e.g., sterile insertion of a central venous catheter], and those that must be adapted to a particular person.”5 Where does all this leave us? Surely some clinical approaches must be superior to others. The growing field of comparative effectiveness research, testing strategies head to head in typical clinical settings, offers promise. It is reasonable to incentivize physicians to adopt better practices. Guidelines can be helpful and payers have a legitimate interest in measuring quality. But ultimately our goal is compassionate and effective care, not uniformity. Quality metrics must not distract us from our principle duties: listening attentively to our patients, examining the clinical data, carefully considering diagnostic possibilities, and applying our knowledge, our technical expertise and our wisdom to the benefit of our patients.

References

1. Makary, MA; Daniel, M. BMJ 2016; 353:i2139.

2. Landrigan CP, et al. N Engl J Med 2010; 363:2124-2134.

3. Kumar, S; Nash, DB. “Demand Better!” Second River Healthcare (2014).

4. Quanstrum, KH; Hayward, RA. N Engl J Med 2010; 363:1076-1079.

5. Groopman, J. The New York Review of Books; Feb 11, 2010.

SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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Quality in Medicine

THE WORST AND BEST OF TIMES Robert Wachter, MD, on Hope, Hype and Harm in Medicine's New Tech Era Steve Heilig, MPH The Digital Doctor is not only the title of one of the most important books about medicine in recent years, but a concise description of current reality. The book’s author, Dr. Robert Wachter of University of California, San Francisco (UCSF), was prodded to spend countless hours researching and writing it by a horrible medical error traced to flaws, both technological and human, in electronic medical records. His interviews with over one hundred leaders in medicine, technology, and beyond produced a book already seen as something of a landmark in this fast-moving arena.

Wachter is Professor and Associate Chair of Medicine at UCSF and Director of Hospital Medicine there; past-chair of the American Board of Internal Medicine and the Society of Hospital Medicine; he coined the term “hospitalist” twenty years ago; and has been a widely-published author since then. Noted physician/author Atul Gawande called The Digital Doctor “the real story of what it’s like to practice medicine in the midst of a painful, historic, and often dangerous transition.”

Your book was published over a year ago, which means you wrote it about two years back. You quote one expert as saying “Now is one of the worst times in history to be practicing medicine.” Is that why you wrote the book?

Well, I had done work on patient safety and was looking forward to computerization as a way to decrease errors. And then we computerized and some things got better but some seemed to get worse. People were saying how wonderful everything was going to be and I was thinking “That’s not what I am seeing or hearing from colleagues!” And then we had a breathtaking error that I don’t think could have happened without computers. My wife is a journalist, and when I told her I wanted to write about these issues she encouraged me to do it as a journalism piece, and talk to many people and see all sides.

Your diagnosis at that point was that rather then being “disruptive and wonderful,” the advent of digital medicine had been mostly just disruptive.

Yeah, and it’s not that satisfying of a diagnosis or excuse to say this sector is as complicated or more so than any other. We tend to think tech can be simple because of how our iPhones work—download an app and there you go. But it turns out that something like Electronic Health Records (EHRs) is an adaptive change that fundamentally alters almost everything about the work and the relationships in medicine. It makes us completely re-imagine our work. Not realizing that going in, we’ve hit a lot of speed bumps.

You note that the reaction among many clinicians has been so negative that one health system attempted to recruit physicians with the promise of “No EHR!” 8

Yes, and that really says how far we missed the mark—you hear so much like “I am now a glorified entry clerk” and so on. So I had to see that people had every right to be unhappy with the early efforts. But I had to also believe that it is going to work out, and I really do believe that—but the question became whether this would happen five to ten years from now or in twenty to twenty-five years.

My book was an attempt to help bring about choices that would shorten that time it will take to get us to the place where it really does make the lives of patients and doctors and nurses better and more efficient and even more fun.

Can you tell of an example that leads to your optimism, at least with respect to EHRs? Sure, look at our latest version of Epic (EHR software), which is still not perfect, but has a “search” box—it was hard to believe that the best-selling, more expensive product did not before now. You couldn’t search for a prior mammogram or Magnetic Resonance Image (MRI), but now you can. Other functions too are better designed now, and it is clear that vendors both older and new are looking hard at realities here. At UCSF we implemented it in 2012, and for the first couple of years it was just trying to get the thing running and not commit mayhem; then it slowed down into a still somewhat uneasy but more productive way of working with it. And people innovated on that scaffolding, such as with an e-consult option where I can send a single quick question to cardiology or gastroenterology and get a quick answer. It wasn’t that hard to add that in but it is so helpful. What you really want is a culture where smart people ask questions about “Why are we doing it this way?” and start to find improvements. It took three or four years here but we are at that stage.

Is it coincidental that we are also at a point where “digital natives” who were born since the advent of such technology are now entering medicine?

Probably not, and some of them really want to go into this— they don’t want to forego patient care, or necessarily be the next Zuckerberg, but to figure out ways to do better, safer, less expensive and more satisfying care, and they understand that this is very likely to have something to do with technology. If you ask many older doctors now about how they like their computer, most will grumble—they go home and answer emails and so on for hours. That’s true and means we haven’t figured out the nature of their work and just piled stuff on them. That’s not right and the new generation is going to figure out ways to make things better.

You wrote much of the “depersonalization” of medicine from tech—looking at, touching, really seeing patients, and even colleagues, less and less.

Yes, I think we’re in a trough there, as again, we provided and

SAN FRANCISCO MEDICINE SEPTEMBER 2016 WWW.SFMS.ORG

even required the tools without knowing how the relationships would be impacted. Besides with patients, we disrupted great relations between, say, radiologists and primary care docs, and younger docs never even knew those. Listen, it bugs me terribly when I am sitting next to one of my kids and they are texting away; on the other hand, two of my kids now live away and I have closer relations with them thanks to FaceTime. So the trick is to ask what kind of communication do we need most with patients and colleagues, and how much of it needs to be in person—and how do we enhance that as well?

What about the potential of telemedicine?

Like many things in tech it’s being over-hyped in the short term, but in the longer run will stick. I think it can work and be OK and some will prefer it—young people won’t want to sit in an office reading a magazine and waiting, as they think that’s crazy. But when a patient is in your office, we do want to be looking at them. That’s partly a problem about how burdensome it is to enter things, and partly about why are we entering so much stuff that doesn’t really lead to better care. I think this will improve now, but for now some are hiring scribes, which is a sort of amusing work-around—only in medicine would we computerize and then immediately start adding personnel to deal with it. Some of the solutions may not be faceto-face ones but technological, and I think that’s OK. When somebody has to drive hours to get a specialty consult, telemedicine can become very useful. Even in my own hospital, wouldn’t it be great if I was with an inpatient and could call up a cardiologist for a quick talk right there on a screen? I think that’s exciting.

Will “artificial intelligence” like the Watson and Isobel computer systems ever replace physicians as some tech gurus predict?

My guess is it will be an augmentation rather than a replacement for most of us. I just did a Technology, Entertainment and Design (TED) talk on this, and said Watson can be very good if you give it five facts—“this is a thirty-two-year-old woman with fever, shortness of breath, on oral contraceptives, chest pain, and a swollen leg,” and Watson will get it right. But we collect three hundred pieces of data, not five, and figuring out which are the salient five turns out to be enormously complicated and is too hard for computers, at least so far. But there will be improvements as we go forward, and computers will be reading more and more x-rays, for example, at least the complex ones. If I were a medical student now looking at specialties, I’d think ones like radiology, pathology, diagnostic dermatology, anesthesiology, and others will see some replacement by computers. I think the bulk of physicians will be safe for twenty or more years, but thirty or forty, who knows?

How about personal health records and wearables?

At this point I think the hype outweighs everything. Part of that is, sure, they can measure my heart rate and sweat rate through a band in my underwear. Maybe some of this will turn out to be useful, but I think people are counting on the desire of certain patients to be obsessive. In certain conditions, like diabetes and measuring sugar, these could be great. But again, there is a lot of smoke and mirrors and many of these companies will be gone.

Is confidentiality of records being improved or compromised in the digital era?

Both. It wasn’t that safe before, you know. But it was hard to get WWW.SFMS.ORG

at a million records in one shot. With records being hacked, we are kind of being beaten up, but all industries are at risk thus far. It really has to become that all of your information is available to everyone you agree needs it, but we need to make this much more secure.

Even sharing among providers—data integration between hospitals and systems—has been a problem to date, due to technology and trust and proprietary concerns.

It’s all of those, yes, especially the trust issues. The Feds are very much in the integration game and hear the message “You spent thirty billion dollars computerizing health records and didn’t insist they all talk to each other?” So they are pushing that hard, and technologically it’s not that hard to do. I think we’ll get it right within five years or so. Locally, it is already much better than it was just a few years ago—here at UCSF we can get records from Sutter or Kaiser much easier than before, but that’s mainly because we all wound up buying the same Epic platform.

Is the dreaded “meaningful use” capable of actually becoming meaningful?

Meaningful use is going to go away, and be replaced by something a bit more benign as part of the Medicare Access and CHIP Reauthorization Act (MACRA). I think the key there is that everybody has learned we didn’t get it right, after a period where some thought it was just dinosaur doctors moaning. Now we hear the head of Medicare saying they got it wrong, and we got past blaming the victims.

So, in summary, in your book you called yourself a non-Luddite who was cautiously optimistic overall. Is that still true?

Yeah, I think even more so now. There was sort of a necessary set of stages here, getting healthcare to go from paper to digital.

Clearly we weren’t going to do it on our own and it took thirty billion dollars and a push to get us going. But it worked—in 2009, twelve percent of American hospitals were computerized, and now it’s over ninety percent. In doctor’s offices it’s not that high, but it’s close. So the first step was to get us computerized; it’s nice to look back and say we should have figured out all the workflow, interoperability, and usability issues, but I just think that wasn’t gonna happen—we had to build the systems and then say “Wait a second, why are doctors so unhappy, and why is burnout so high, and what can we do to fix it?” Leaders weren’t being stupid or malicious; this was very hard. I think we are now seeing the unanticipated but in hindsight relatively predictable downsides. And I think none of them are insurmountable. The healthcare system is just not going to work very well if half our doctors are burning out, so we just have to fix things. And I think we will—I think the tides have turned for the better.

SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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Quality in Medicine

HEALTHCARE QUALITY MEASURES A Contradiction in Terms?

Michel Accad, MD Fifteen years ago, the Institute of Medicine (IOM) issued a jolting report titled Crossing the Quality Chasm: A New Health System for the 21st Century. In that docu-

ment, the IOM enjoined the healthcare community to take stock of dire quality deficiencies in our medical system, and take steps to remedy the situation. In response, an entire industry of private and government agencies sprang into action with great fervor and hope.

Today, however, the mood is less optimistic. Doctors are pushing back against a proliferation of quality metrics that impose onerous administrative demands without yielding tangible improvements in return. For example, one doctor recently remarked on Twitter that if one measures something, perhaps that something is a quantity rather than a quality.

He may have a point. “Quantifying quality” sounds a bit contradictory, especially if we recall that, in a classical sense, a quality is a characteristic that simply distinguishes one thing from another of the same kind.

For example, “muffled,” “hollow,” or “thunderous” are qualities that distinguish one sound from another. “Rough,” “taciturn,” or “pleasant” are qualities that distinguish different personalities. In general, qualities segregate things into categories according to the subjective experiences one may have of those things. Quantification plays no role in determining qualities.

It is true that a sound can be more or less muffled, but once we focus on how muffled the sound is, we are no longer interested in “muffledness” as a quality per se. A slightly muffled sound or a highly muffled one all belong to the family of muffled sounds. They all share the same quality.

The same consideration goes for discriminating between something good and something bad. Goodness and badness are important qualities that express the ultimate reason for approving or disapproving something: We approve of this product because it is of good quality; we disapprove of that service because it is of bad quality.

Note that the stipulation is coincident with the choice: It is not as if we first determine whether something is good or not and then apply our seal of approval. We approve of something because we have experienced it as good (or vice versa: if we experience something as good, we approve of it). That being the case, there is no room for “measuring” good quality. It can only be experienced.

Of course, an immediate objection to what I have just said is that we are surrounded in our everyday lives with quality scales for consumer goods and services. No one seems to complain against Michelin stars or Yelp ratings, so why couldn’t similar “metrics” guide us in healthcare?

In my judgment, the use of quality measures in our profession is problematic for several reasons.

First, consumer ratings are simply testimonials reflecting othWWW.SFMS.ORG

er people’s experiences and opinions. They are widely recognized as being subjective. Furthermore, they are produced for the sake of consumers. In contrast, healthcare quality measures are put in place primarily for the sake of insurers, and particularly for the Medicare program. The interest of these entities may not be the same as the interests of patients.

Second, because healthcare is generally paid for by insurers, patients lose an important independent indicator of quality: market prices. A freely set market price is one of the most reliable signs of quality, because such a price is the end result of voluntary exchanges between large numbers of consumers and producers. In a system dominated by third-party payment, however, prices do not reflect the needs and satisfactions of patients. Instead, they mainly convey the outcomes of negotiations between providers and payers.

Third, healthcare is highly regulated. As a result, quality measures are essentially arcane rules articulated in bureaucratic lingo.

Unlike rating systems for consumer goods, where one can directly verify the veracity of the report, healthcare quality measures invite ambiguities, errors, and obfuscations.

Finally, medical care consists of choices and decisions made in the face of inherent uncertainty. Unlike a hamburger or a hotel room, every human being is unique, with constituent ingredients that are beyond the complete control of healthcare workers. Therefore, the quality of a coronary bypass or that of a stay in the intensive care unit must be gauged in real time, in its specific context, and in light of all possible alternatives. Government regulators, third-party payers, and auditing agencies are far removed from these contextual details. Their quality determinations are unlikely to be more accurate than those spread by word-of-mouth from patients who have experienced the care.

In conclusion, when it comes to promoting quality in healthcare, the words of sociologist William Bruce Cameron come to mind: “Not everything that can be counted counts, and not everything that counts can be counted.”

Michel Accad, MD, FACC, is a San Francisco cardiologist and internist in solo private practice. He is founder and medical director of Athletic Heart of San Francisco, a sports cardiology clinic dedicated to serving the cardiovascular needs of athletes and physically active men and women. He is also HS Assistant Clinical Professor of Medicine at UCSF/SFGH, Division of Cardiology.

Dr. Accad is a member of the editorial board of San Francisco Medicine.

SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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Quality in Medicine

BIG DATA AND BIG MISTAKES Is Our Information Today Better Or Is There Just More Of It? Kevin R. Stone, MD “Big Data” refers to the mining of enormous data banks for trends, patterns and strategies for influencing decision-making in an informed way. One ex-

ample of this is hospital Electronic Medical Records (EMR). In this case, vast amounts of data are collected, pooled and analyzed by insurance companies, drug companies, researchers and anyone interested in understanding the health of patients and the consequences of various treatments. But does it work?

Not really. The joke in hospitals these days is that if a patient comes in for an amputation of his leg, you can counsel him not to worry: When he returns to the hospital for something else— skin cancer, for example—his leg will be back on. Why? Because while the doctor admitting the patient for the skin cancer might comment on that particular problem, he is also highly likely to cut and paste into the new record the results of a long, obsolete physical exam in which the leg appeared as normal.

And this is not just the fault of doctors. Everyone in the hospital has to hunt and peck to fill in these computerized records, and no one has the time to do it.

It is not just the medical records that are contaminated by obsolete information. The entire fields of “consensus medicine” or “standards of care” are suspect. In orthopedics, there are very few Level 1 studies proving the efficacy of one device over another. Large pooled studies (such as meta-analysis or Cochrane analysis) often get their data from very few or very poor studies.

The input data is weak, at best.

Therefore, big data suffers from the old “garbage in, garbage out” problem of trying to digitize human characteristics. While it’s well-meaning, and possibly an improvement over the old paper records, one has to ask: “Is the quality of our data better today than it was ten years ago, or is it just larger?” Are the conclusions about which treatments work and which should be approved—drawn from the hospital EMR and used by insurers and the government —based on facts or fictional convenience?

There are solutions to this problem. The EMR, for one, needs an artificial intelligence agent monitoring the inputs. The inputs should be oral with logical prompts. Doctor: “I would like to admit this patient for a knee replacement.”

“Okay,” the record responds, “I note she had a blood clot in the past. Shall we order anti-coagulation specific to her genotype?”

Only when this real-time feedback is in place will medical records evolve logically and accurately and be truly useful in fulfilling the promise of data mining.

Further, all doctors—and not just at the major medical centers—need to use outcomes tools as part of their patient care plans. Any patient given a drug or therapy must have an easy way to add their information to the mix. This could be done with 12

a follow-up questionnaire or automated call to discover if the therapy works. Since everyone has a cell phone, and almost no one ever changes their cell number, no patient should ever be lost to follow up.

There need be no more confusion about whether or not a patient will be bringing one leg or two to their next appointment. The tools are now available for our Electronic Medical Records to be accurate, comprehensive and updated in real time.

That’s when these big data recommendations will turn Big Data into Big Results.

Kevin R. Stone, MD, is an orthopedic surgeon at The Stone Clinic and the Chairman of the Stone Research Foundation. He has lectured around the world as an expert in cartilage and meniscal growth, repair and replacement. Dr. Stone has pioneered new ways to address biologic as opposed to bionic (artificial) joint replacement. As an orthopaedic surgeon, he has served the U.S. Ski Team, the U.S. Pro Ski Tour, the Marin Ballet, the Smuin Ballet, the modern Pentathlon at the U.S. Olympic Festival, and for the U.S. Olympic Training Center.

SAN FRANCISCO MEDICINE SEPTEMBER 2016 WWW.SFMS.ORG

Quality in Medicine

CAN’T HEALTH IT BE MADE BETTER? Disruptive Isn’t Always Productive Art Papier, MD In a keynote address last month, American Medical Association Chief Executive Officer James Madara, MD, likened many of the digital health products saturating the

medical landscape to “snake oil,” earning a host of comments and reactions in the medical tech world. Dr. Madara in particular focused his wrath on direct-to-consumer health apps and ineffective electronic health records (EHRs). But does hucksterism and hype end with digital health information in medicine? What about expensive new “miracle drugs” that almost bankrupt patients and are later proved to have minimal benefit? Or research breakthroughs that are news headlines and never pan out? The fact is that we are enamored with the latest and greatest—what’s hot, what everyone is talking about. So let’s add to the list of buzzwords: “analytics,” “big data,” “proteomics,” “biomics,” and “precision medicine” are just a few new words promising the transformation of your health.

What fascinates me about the current health technology landscape is how the quest for new is diverting technology development away from the essential challenges of practicing clinical medicine today. I think this is what Dr. Madara is speaking to.

There are a billion outpatient visits in the United States each year, three on average for every American. If half the visits are for management of existing problems, the other five hundred million visits include symptoms, complaints, and problems requiring answers. These visits where problems are to be solved and diagnoses made are inconsistent, spontaneous, and often maddeningly frustrating to patients. Patients present to their doctors (and now often nurse practitioners and physician assistants) expecting the most accurate and precise care possible. What they actually receive in care is entirely dependent on who they see, where they are seen, and other factors mostly out of their control. In the patient’s eye, it is readily apparent that these doctor visits are ad hoc, unstandardized, and varied in results across practitioners. The result is that ten to twenty percent of all diagnoses are just plain wrong.

Care is increasingly complex and yet fragmented between specialists. There is an ever-growing body of medical literature and recommendations to keep up with. Increasing time pressures on physicians to conduct fast evaluations leads to missed patient histories and cognitive mistakes such as premature closure and diagnostic error. EHRs have mostly added to cognitive burden, not reduced it. These are core problems in medicine today.

Last year, President Obama announced a bold new focus on precision medicine. What new program in “precision medicine” should the President have announced first? Clinomics. I’m defining Clinomics as precision clinical care to deliver what medical science already knows. It entails bringing the excellence in pre-existing, readily available knowledge to the fingertips of the doctor and patient at the time of the visit and to the patient at home. This means highly relevant information applied to clinical decisions that are WWW.SFMS.ORG

contextualized to the patient problems. This is information existing in today’s medical literature that is not being delivered to the decision-making moment, but easily could.

Clinomics is also defined by thoroughness and completeness in medical practice, and using information precisely to aid diagnostic, testing, and therapeutic decisions. Clinomics encompasses: • A thorough history and physical exam • Meaningful patient engagement • Shared decision-making • Patient-contextualized digital information to aid decisions • An easy-to-use electronic record to support all of the above

If we focus on productive technology, we can bring back the joy of practicing medicine. Instead of clicking buttons to fulfill bureaucratic functions in bloated EHRs or working with apps that supply meaningless and superfluous information, we can fix the known repeated mistakes that anger and harm patients. The technology of Clinomics helps doctors with actual medical thinking. With Clinomics, patients marvel as their doctors use purposefully designed information tools that are much more powerful than random and imprecise Google searches.

Clinomics dovetails with the precision medicine of genomics, biomics, and proteomics, and will provide such promising endeavors with context and an organizing principle around clinical medicine, leading to these new sciences accurately linking clinical phenotype to molecular information.

Tech plutocrats with billions for “moonshots,” and those that must use the clichés of “disruption,” “big data,” “analytics,” and “precision medicine” will think I am a Luddite. I’m not. Health information technology is the key to enhancing medical decision-making.

And despite Dr. Madara’s skepticism, consumer-focused applications are critically needed innovations that have the potential to transform health and the physician-patient relationship in the most positive ways. However, innovators must also focus on technologies that address core needs in the exam room. Provide doctors with user interfaces and tools that work so they can do things like order the most sensible, appropriate, and cost effective lab tests. Make sure the diagnosis is correct, and the therapy ideal. Understand medicine and the inherent ambiguity of medical decision-making.

You cannot fix anything if you fail to understand and misstate the core problems. We can start fixing the broken here and now as we envision and invest in the future.

Art Papier, MD, is the co-founder and CEO of VisualDx. A dermatologist and medical informatics expert, Papier is also an associate professor of dermatology and medical informatics at the University of Rochester School of Medicine and Dentistry. He is a thought leader in clinical informatics and healthcare solutions that improve diagnostic accuracy. This article was reprinted from www.medpagestoday.com.

SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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Quality in Medicine

OUT OF THE OFFICE Tale Of A Suicide, The End-of-Life “Option” We All Deplore John Maa, MD, FACS I had with me the trauma surgery call pager for Marin General Hospital, where bridge victims are brought if there are still signs of life after their extraction from the cold waters of the bay. The trauma pager was never activated in the hours after this event.

In 2014, the Golden Gate Bridge board of directors unanimously approved the installation of a safety net to deter suicide attempts and raised funds in hopes of beginning construction by late 2017. Thank you to those who have dedicated their time and efforts to erecting a safety barrier on the bridge. Before long, hopefully, events like this will be only a distant memory.

Dr. Maa, a surgeon at Marin General Hospital, is past president of the Northern California chapter of the American College of Surgeons. He is a member of the SFMS Board of Directors and of the San Francisco Medicine Editorial Board.

On the Friday evening of Memorial Day weekend in 2015, I was driving into San Francisco across the Golden Gate Bridge. Northbound traffic was heavily con-

gested around mid-span, as the right lane was closed. Emergency vehicles with flashing lights re-directed traffic to the left lanes. As I approached the bottleneck, I noticed a backpack leaning against the railing and saw two bridge security officers who appeared to be gesturing in the direction of Alcatraz. I quickly realized that they were pointing not at the prison, but instead at a person holding his head in his hands and seated on the ledge outside the railing.

I drove to the southern end of the bridge as police cars with sirens blaring raced toward the scene. I parked in the south lot, and began walking back toward Marin. The skies were gray, and the red lights of the patrol vehicles colored both the water below and the clouds above. As I approached the toll plaza I noticed a new color flickering on the water’s surface. It was from the distinctive white flare that is dropped by Bridge security to mark the spot where a person has fallen and guide search-and-rescue efforts by tracking the direction of the currents.

A gray Coast Guard vessel matching the color of the sky could now be seen racing westward to the scene from Fort Baker, just past the north end of the bridge. It paused near the smoke of the flare and then continued to the other (i.e., west) side of the bridge, where it stopped and circled. It lay motionless on the water for about four minutes and could then be seen rushing back toward Fort Baker, where an ambulance was waiting. As I kept walking toward the site of the bottleneck, I saw that traffic had again begun moving normally. A grim-faced bridge security officer drove past in a small white vehicle that was otherwise empty.

I reached the site of the disturbance, which was now deserted without any trace of the preceding events. As I turned and walked back to San Francisco, I passed joggers, pedestrians and tourists who likely knew nothing of what had just taken place. On returning to the south plaza, I noticed that the ambulance had not left Fort Baker.

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Quality in Medicine

HEALTH POLICY PERSPECTIVE Good Medicine And Bad Abortion Politics Don't Mix

By Pratima Gupta, MD and Steve Heilig, MPH People go to doctors for educated, compassionate advice and help with their personal health problems. Al-

most one third of American women will at some point seek a doctor for help ending an unwanted pregnancy. That can be a difficult decision, but a vocal minority of people continually attempt to make it even more so—or impossible.

And sometimes they are downright sneaky about it. Their latest strategy has been to push state laws requiring physicians who perform abortions to obtain admitting privileges at local hospitals and that every health care facility offering abortion services meet the same building specifications as ambulatory surgical centers—small hospitals, in essence. But abortion is extremely safe, with a less than a one percent complication rate—nearly equivalent to colonoscopy.

As it is clear that these requirements have nothing to do with actual patient safety, the Texas law wound up at the Supreme Court.

That court wisely ruled against such restrictions, noting they placed an “undue burden” on women and that “there was no significant health-related problem that the new law helped to cure.” Now efforts begin to void at least eight other such state laws.

Since this is about doctors providing care to women, what do actual doctors think? The American Medical Association—hardly a radical feminist group—weighed in strongly against the Texas law, noting “The AMA opposes laws regulating medical care that are unsupported by scientific evidence and that impede, rather than serve, public health objectives.” The national associations of obstetricians, family physicians, pediatricians, and others joined in this protest, noting that nothing in the restrictive laws would do anything to improve care or safety.

It is gratifying when the nation’s highest courts agree with the old slogan “doctor knows best.” Who would know better in such cases? Well, perhaps women as well, and in addition to the Supreme Court’s three female justices, many women submitted statements to the court as well, detailing their sometimes wrenching stories of being denied reasonable access to care.

Women will continue to need and have abortions no matter what sort of “undue barriers” are in place. Some will be desperate enough attempt to perform abortion themselves when they cannot access safe care. The Texas Department of State Health Services noted there was a significant decrease in the number of early medication abortions and women of color were disproportionately impacted. In other words, the anti-abortion laws actually resulted in some later abortions—presumably something few if any anti-choice advocates would want.

Anti-abortion politics and medicine don’t mix, at least not in any useful manner. Planned Parenthood, for example—currently the irrational focus of many attacks and even being used to derail funding for fighting the brewing Zika pandemic—very likely prevents more abortions than any amount of anti-choice rulemaking.

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Likewise for the longstanding bans on funding of abortion here and abroad via the counterproductive Hyde and Helms acts, which have likely resulted in more death and harm than anything else. Mandates for waiting periods, inaccurate information that must be provided to patients, non-indicated ultrasound exams, and phony anti-abortion offices masquerading as “clinics” as helpful do not help anybody.

Here in San Francisco, with our long tradition of respecting women’s reproductive freedom, we have seen patients who have traveled across state lines to receive evidence-based and free-frombias care. It is good that we offer that here, but women should not have to travel to receive it. The San Francisco Medical Society has long been a leader on these issues, favoring full coverage of contraception options, full access to medical abortion as indicated, evidence-based sexual education, and more—even without a fully unanimous “pro-choice” position among all members. Physicians know that evidence and compassion come first.

How can we have pride in our nation that is waging what has been termed a “war on women” at home and abroad? Despite this recent Supreme Court win, it will take time for Texas and other states with restrictive legislation to recover and rebuild their reproductive health clinics to serve their diverse patient population. In the meantime, here in San Francisco we must continue to do good research, advocate, and ensure that all know “the doctor is in.”

Pratima Gupta is an obstetrician/gynecologist practicing in San Francisco, an SFMS delegate to the CMA, and a newly-elected member of the San Francisco Democratic County Central Committee. Steve Heilig is on the SFMS staff and is an editor of both San Francisco Medicine and the Cambridge Quarterly of Healthcare Ethics.

Workplace Violence against Health Care Workers in the United States - from N Engl J Med 2016; 375: August 18, 2016 To the Editor: As an abortion provider, I write in response to the review article by Phillips. My heart goes out to the families of the victims cited in this article and to all who have endured workplace violence. However, I want to bring attention to the omission of violence toward abortion providers. Clinic staff at all levels have been targeted and harassed, facing threats of violence, bombings, and arson. According to the 2015 Violence and Disruption Statistics by the National Abortion Federation, there has been a dramatic increase in hate speech, internet harassment, death threats, attempted murder, and murder. There is no other area of medicine in which health care providers endure protesters at work and at home, use pseudonyms, wear bulletproof vests, or take different routes to work every day, all to ensure personal safety and the safety of their patients. The health care community must work together to prevent further disruption of patient care and escalation of violence in the health care setting.

—Pratima Gupta, MD, MPH | Physicians for Reproductive Health SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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PAYOR REIMBURSEMENTS HEALTH CARE

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Getting Ready for ICD-10: 2017 Style

The launch of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD10) happened more than nine months ago and we are nearing the end of the Centers for Medicare and Medicaid Services (CMS) imposed “period of flexibility.” At the same time, October 1, 2016 will also bring the addition of new codes to the ICD-10 system.

What does this mean for your practice?

With the end of the so-called “grace period” or period of flexibility that CMS allowed from October 1, 2015 through September 30, 2016, will more claims be denied?

With the sunset of the twelve-month flexibility period, it is likely some practices may see a few more claim denials. If you have been doing a good job of coding—coding to the highest level of specificity, coding underlying illnesses and conditions when appropriate and documenting thoroughly—then you probably won’t see an increase in claim denials from payers. However, if you have been using valid ICD-10-CM codes, but not necessarily coding to the most specific code—e.g., coding unspecified laterality when you should be specifying either right, left or bilateral—then you may see some payers begin to deny claims or pend claims until a higher specificity of coding is reported. Remember, at the same time the flexibility period ends, the first set of new codes we’ve gotten for ICD-10 in four years will be implemented, so there is the possibility of some claims being denied for invalid codes if you have not updated your systems to incorporate new codes and remove any old codes that have been deleted.

What do we need to be doing to get ready for the expiration of the period of flexibility?

Providers should continue to educate, audit, and reinforce the need for specificity in all appropriate codes. Specificity is already a critical component of the revenue cycle for document18

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ing, coding and reporting outcomes—get in the habit of documenting and coding in highest level of specificity for all services and all payers. Continue to identify any denials received, correct them immediately, and educate so they don’t happen again.

Here’s an easy task you can do to minimize the risk of increased denials: Generate an ICD-10 code frequency report for the last three months; look for codes ending in “9”; pull patient records where any of these codes were used; and evaluate the documentation for errors that could have prevented the use of the nonspecific code and led to a more specific code selection.

Where can I get a list of the new ICD-10 codes for 2017?

ICD-10 coding changes for 2017 will be implemented on October 1, 2016. A list of the additions, deletions, and changes are posted on the Center for Disease Control and Prevention National Center for Health Statistics website and can also be found at https://www.cms.gov/Medicare/Coding/ICD10/2017ICD-10-PCS-and-GEMs.html. While there are approximately fifty-five hundred new codes, the majority of those are in the ICD-10-PCS (procedures) category. For ICD-10-CM (diagnosis) there are 1,974 code additions, 311 deletions, and 425 revisions.

The resulting total is 71,486 ICD-10-CM codes.

Briefly, here are some of the changes you can expect:

• New code for Zika virus • Further specificity of diabetic retinopathy and the ability to capture macular edema has resolved after treatment with laterality • New codes for hoarding, and various obsessive-compulsive disorders • Laterality reporting for carpal tunnel disorder, tarsal tunnel disorder, and various lesions of specific nerves • Expansion of stages of primary open angle glaucoma and code for amblyopia suspect • Added hearing loss with additional information in rela-

SAN FRANCISCO MEDICINE SEPTEMBER 2016 WWW.SFMS.ORG

tionship to the contralateral ear; new code for pulsatile tinnitus • Updates in the Circulatory chapter include addition of hypertensive urgency, emergency, or crisis; reducing specificity of nontraumatic subarachnoid hemorrhage and the communicating artery • Addition of codes for numerous dental conditions • New codes for preorbital cellulitis and excessive and redundant skin and subcutaneous tissue • Musculoskeletal chapter added bunion, bunionette, pain in joints of the hand, more specificity to temporomandibular joints, cervical disc disorders at specific levels, atypical femoral fractures, and periprosthetic fractures • New codes for more specific urinary incontinence conditions, erectile dysfunction, ovarian cysts and conditions of the fallopian tubes • Added various conditions involving ectopic pregnancy, pre-eclampsia, severe pre-eclampsia, and eclampsia complicating childbirth and puerperium • Two new codes for newborn light for gestational age • Addition regarding specific fractures to bones of skull and various fracture types of the foot • Additions to complication types including breakdown, displacement, infection, erosion, exposure, pain, fibrosis, thrombosis, and leakage • Addition of external cause code for activity of the choking game, as well as addition of code for overexertion • Z code additions for a variety of observation of newborns for various conditions, encounter for prophylactic medications, conversion of endoscopic procedures to open, and long term use of oral hypoglycemic drugs

Every practice should purchase a current edition of ICD-10-CM for their practice from their favorite medical publishing house to assure they are using the most up-to-date codes.

Questions and answers provided courtesy of the Cooperative of American Physicians, Inc. and Mary Jean Sage of Sage and Associates. The Cooperative of American Physicians, Inc. (CAP), established in 1975, offers medical professional liability protection and risk management services to nearly twelve thousand of California’s finest physicians through the Mutual Protection Trust. In 2013, CAP organized CAPAssurance, a Risk Purchasing Group, to bring liability insurance coverage to member hospitals, health care facilities, and large medical groups. Based in Los Angeles, CAP also has offices in San Diego, Orange County, Sacramento, and Palo Alto. For more information, visit www.CAPphysicians. com. The Sage Associates is a leading multi-specialty provider of high quality healthcare management consulting services. If you have questions related to the information in this article, contact Mary Jean Sage at 805-904-6311 or visit her website at www. thesageassociates.com.

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SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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One Hundred Fifty Years of Laguna Honda

Front row: Emily Kinebuchi, Monica Banchero-Hasson, Michelle Murphy, Brenda Austin, Seema Sharma, Vicky Young. Second Row: Elaine Gecht, Yifang Gian, Michael McShane, Helena Leiner, James Prince, Wilmie Hathaway, Alkarim Jina, Michael Coleman, Christopher Hinnant, Shahib Aghamir, Susan Sabai, Vera Chow, Yeva Johnson Thousands of pioneers migrated to San Francisco in the 1840s with dreams of becoming rich during the Gold Rush. Instead, many fell ill due to harsh mining conditions and later a smallpox epidemic. In 1866, the City opened what is now known as Laguna Honda Hospital and Rehabilitation Center (Laguna Honda) in response to the increasing need for housing and medical relief services.

Situated on sixty-two acres of land, Laguna Honda has transformed many times over the years. It originally started as an Almshouse to provide housing for the indigent, later adding a twentyfour-bed medical facility in response to a small pox epidemic. It was accredited as a skilled nursing facility in 1963, and became the site of a cancer research program funded by the National Cancer Institute and the University of California. The hospital now offers a comprehensive array of post-acute care services. Although the medical staff composition have changed over the last one hundred fifty years, Laguna Honda clinicians remain steadfast in providing resident-centered care to the population of San Francisco.

The medical staff at Laguna Honda is led by Dr. Michael McShane, senior physician and current acting Chief Medical Officer. McShane, along with his medical executive team, oversee clinical and programmatic planning of services that are carried out by clinicians working for the San Francisco Department of Public Health. Together, the diverse team of clinicians is able to care for more than seven hundred fifty residents daily. Inpatient services include general skilled nursing care, behavioral health, and rehabilitation therapy as well as specialized palliative, dementia and positive care. Laguna Honda also has an outpatient clinic with twenty-eight different sub-specialties that is staffed by medical consultants from the University of California, San Francisco. “Our teams have a diverse background and everyone comes from mixed disciplines with different expertise. We are all passionate 20

about serving our residents and when we are presented with challenges and service needs, everyone is willing to roll up their sleeves and help,” explains Dr. Yifang Qian, Chief of Psychiatry.

The focus for the medical staff is to promote a feeling of community while encouraging individual choice with the residents. They are committed to using evidence-based practices to improve patient outcomes. The success of this approach can be seen through the evolution of the Positive Care program at Laguna Honda. Since 1989, there has been a dramatic decrease in expirations of residents with HIV/ AIDS following admission. Residents in the Positive Care program have also seen an increase in life-expectancy. Related, the percentage of residents with HIV/AIDs being discharged back to into the community have also increased. These trends coincide with advancement in treatment for HIV/AIDs without a doubt, but it takes a multidisciplinary team of clinicians to treat both the biological and sociological symptoms of HIV/AIDS. Laguna Honda clinicians take pride in working together and have adopted the Resident Care Team (RCT) model in order to track and follow the progress of residents throughout their stay at the facility.

This is advantageous to residents since many are admitted with comorbidities that cannot be treated in isolation. Physical Medicine and Rehabilitation, Behavioral Health Services, and Medicine Services are led by service chiefs Dr. Lisa Pascual, Dr. Yifang Qian, and Dr. Monica Banchero, respectively. Pascual and Qian work with Banchero collaboratively to provide integrated clinical care for Laguna Honda residents, many of whom have complex medical and mental health issues, and require extensive rehabilitative services. “I feel we get the best out of our residents,” Dr. Banchero explains. “Our residents thrive here because we listen to them and work with them to create personalized care plans that are most suitable for their goals.”

The outpatient clinic at Laguna Honda is guided by Dr. Christina Lee, who ensures that residents have timely access to sub-specialty care, including dental services. In addition to residents, staff are also able to utilize the outpatient clinic for preventive services such as annual Tuberculosis testing and flu vaccinations. This creates a care environment that is safe and compliant.

Part of what motivates the medical staff is the new state of the art facility that is Laguna Honda. With natural light and large outdoor spaces, the five-year-old building serves as an ideal healing environment. There are plans in the near future to invest and implement a new electronic health record system along with other technologies that will enhance the resident care experience at Laguna Honda. This influx of change and innovation is carefully being blended in so as to not deviate too far from its Almshouse roots. Long known for its long term care of the elderly and disabled, Laguna Honda now also looks to build a reputation for its ability to provide short-term medical services and rehabilitation therapy that allow residents to be reintegrated into the community with hope. The compassionate, dedicated and highly skilled medical staff is moving Laguna Honda towards a goal of being a leader in and model for post-acute care in the nation.

SAN FRANCISCO MEDICINE SEPTEMBER 2016 WWW.SFMS.ORG

MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

Dr. Jesse Liu has been named as the new Chief of the Division of Gastroenterology/Hepatology effective July 1, 2016. Dr. Liu has been Director of the California Pacific Medical Center (CPMC) Gastroenterology Fellowship Training program since 2013, and is adding the Chief’s duties to his leadership responsibilities. Many thanks to Dr. Richard Sundberg for his past services as Division Chief.

Sutter Health launched a new medical transport network serving the critically ill, injured and most fragile patients needing to transfer to higher levels of care in Northern California. CPMC’s stroke specialist, Dr. David Tong, has been instrumental in the planning of the new network, which features a fleet of branded air ambulances (helicopters and fixed wing aircraft) operated by California Shock Trauma Air Rescue (CALSTAR), and a fleet of ground ambulances operated by American Medical Response (AMR). The air and ground ambulances are strategically located across Northern California to meet the growing demand of patients needing transfers.

A palliative care physician at CPMC is among the fifty-plus contributors whose ideas are being more closely studied in our global online conversation on improving the endof-life experience. This online conversation is hosted by OpenIDEO and sponsored by Sutter Health, with support from the Ungerleider Fund, Better Health East Bay Foundation, and others. Contributors around the globe have offered more than three hundred ideas in the initial phases of the conversation. Our collective goal: to identify and support compassionate solutions to improve the end-of-life experience for those who are dying—and their loved ones. Dr. Ken Rosenfeld, a hospice and palliative care expert who practices at CPMC, submitted two ideas included on OpenIDEO’s refinement phase list. First, he suggests a tablet-based display to digitally personalize the Intensive Care Unit experience for patients, families and providers. He also proposes a more personalized “death garment” in lieu of the clinical-looking body bag used to encase a deceased person.

WWW.SFMS.ORG

Kaiser

Maria Ansari, MD

In our continued pursuit to provide the best care possible and choose wisely for our patients within the framework of Kaiser Permanente’s integrated model, we currently use several methods and tools that help us achieve our goals. These include collaboration across primary care and specialty medicine disciplines as well as our electronic medical record (EMR) system, KP HealthConnect.

Physician communication, supported by the EMR, is how we view and analyze a patient’s medical history to help inform a current treatment plan. Our primary care and specialty providers are able to discuss cases in real time through a multitude of modalities, including phone, email, texts, and video.

We therefore reduce unnecessary and redundant testing. For the patient, this means fewer appointments, lowers costs, and safer outcomes (for example, an Emergency Room doctor may consult a neurologist by video at the patient’s bedside and therefore know how to treat an urgent neurologic condition, and may help the patient avoid extra radiation exposure or repeated lab evaluation.)

All clinicians access results in real-time, even outside of the medical facility or across the country.

The EMR also enables providers to reduce errors with built-in, evidence-based treatment recommendations, guidelines, and links to further proof for best possible decision-making. Information regarding such conditions as sepsis, blood clots, and urinary tract infections are available at the providers’ fingertips by simply accessing the medical record.

Ultimately, by communicating across disciplines in real time consultation, collaborating on treatment plans using the cutting edge tools available to us, and accessing the most current information on a specific condition, we are choosing wisely for our patients in the timeliest and most cost-efficient manner possible.

SPMF

Robert Osorio, MD, FACS

When clinicians gather with their colleagues to explore data about their treatment patterns, they are usually surprised by the variation in the delivery of health care services.

Often it’s the first time they have seen such individual and cumulative utilization data about their practice patterns. The information sparks a desire to dig deeper and address variation in how they care for their patients. With quality outcomes for the patient in mind, physicians across Sutter Health’s five medical foundations, four Independent Practice Associations, and several hospitals are making clinical variation reduction a priority. Clinicians are working to address more than seven hundred clinical variation reduction opportunities throughout the Sutter Health system. Sutter Pacific Medical Foundation (SPMF) launched its Variation Reduction Program in December 2012. Since that time, clinicians have launched ninety-two projects, and in a period of twenty-four months they have reduced health care spending by $578,000. Clinicians in over fourteen SPMF specialties are participating.

One highlight of SPMF’s Variation Reduction Program includes a project to promote shared decision-making around cervical cancer screening. Obstetricians and Gynecologists came together to review data showing variation in how frequently they were performing Pap testing to screen for cervical cancer. They adopted a standard aligned with American College for Obstetrics and Gynecology (ACOG) to reduce the frequency for Pap testing. They partnered with patients to discuss the best screening frequency and were able to reduce the percent of Paps performed more frequently than what ACOG recommends from fifty-one percent to thirty-seven percent. By basing their care on evidence and data, our providers have been able to improve health care delivery without compromising patient care. Finding opportunities to standardize care based on best practices can reduce variation in health care delivery, and potentially enhance patient care and avoid high utilization and waste.

SEPTEMBER 2016 SAN FRANCISCO MEDICINE

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UPCOMING EVENTS SFMS Physician Networking Mixer October 6, 2016 | 6:00 p.m. to 8:00 p.m.

Location TBD Sponsored by the Cooperative of American Physicians Contact Erin Henke at ehenke@sfms.org or (415) 561-0850 extension 268 for more information or to RSVP.

CMA President’s Reception and Awards Gala

October 15, 2016 | 6:00 p.m. to 10:30 p.m.

Sacramento Memorial Auditorium, Sacramento Contact Sadye Reish at (916) 551-2030 or sreish@cmanet.org for more information.

SFMS Practice Manager Networking Mixer

September 29, 2016 | 5:30 p.m. to 7:00 p.m.

Mechanics Bank, 343 Sansome Street, San Francisco Sponsored by Mechanics Bank, with support from Northern California MGMA Contact Erin Henke at ehenke@sfms.org or (415) 561-0850 extension 268 for more information or to RSVP.

ZERO Prostate Cancer Run/Walk San Francisco

November 12, 2016 | 9:00 a.m.

Lake Merced, San Francisco For more information, visit www.zeroprostatecancerrun.org/ sanfrancisco.

UPCOMING CMA WEBINARS

2016 Ballot Measures: How Your Vote Can Increase Access to Care September 28, 2016 | 12:15 p.m. to 1:15 p.m.

Free for members www.cmanet.org/events This webinar will present an overview of the 2016 ballot initiative campaigns in which CMA is involved, with a focus on their impact on patient access to care and the state of health care in California. We will also briefly review other initiatives CMA has taken a position on.

CHPI Physician Quality Rating Program: Navigating the Review and Corrections Process

October 5 | 12:15 p.m. to 1:15 p.m.

Free for members www.cmanet.org/events With the California Healthcare Performance Information System (CHPI) publishing clinical quality ratings for approximately 13,000 California physicians later this year, physicians will soon begin receiving notices advising of their quality scores along with information on how to access the review and corrections portal to confirm or correct their data. This webinar will provide an overview of the CHPI quality rating project, along with stepby-step instructions on how physicians can review their data for accuracy before the quality scores are published.

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SAVE THE DATE: SFMS Annual Gala

Friday, January 27, 2017 | 6:30 p.m. to 9:00 p.m.

Asian Art Center, San Francisco Join SFMS for our Annual Gala! Come together with many of San Francisco's most influential stakeholders in the medical community to celebrate SFMS' one hundred forty-nine years of physician advocacy and camaraderie. Man-Kit Leung, MD will be installed as the SFMS President. Guests will be treated to an exquisite reception with elegant hors d'oeuvres and libations. Ticket information will be available online soon at www.sfms.org.

SFMS URGES EMERGENCY SERVICES IMPROVEMENT Months ago, the SFMS and the San Francisco Emergency Physicians Association urged the San Francisco section of the Hospital Council of Northern California to undertake an in-depth study of how to improve local emergency services. To their credit, the Hospital Council has now commissioned such a study and report, which is well underway. Some of the reasons for this effort are outlined in our letter below; more to come on this hopeful project.

March 21, 2016 - To Warren Browner, MD, Chair; David Serrano Sewell, Executive Vice-President, Hospital Council of Northern California

Dear Dr. Browner and Mr. Sewell: We write in support of a growing effort to commission an independent study of San Francisco's emergency and disaster capabilities and system, with implementable recommendations for improvement. We know you are all too aware of the longstanding local challenges of ambulance diversion, increasing overload in emergency departments, worsening acuity of problems such as mental health and substance abuse-related conditions, suboptimal response times, treatment delays, lack of referral resources, and more. With recent growth and development in our city, especially on the "East side" including Mission Bay, and increased traffic everywhere, these problems are becoming even more acute. The gradual aging of our population, with attendant higher ED utilization, will add yet more pressure. Finally, our vulnerability to a large-scale disaster, whether earthquake, airline or aquatic incident, or epidemic outbreak is undeniable.

The result of all this is a volatile situation with diminished quality and increased cost. 911 calls, ED visits and diversions are all increasing. Some other major cities, experiencing similar problems, have implemented innovations that San Francisco might adapt and adopt.

At a recent board meeting of the San Francisco Medical Society, with representatives of all local private and public hospitals present, there was unanimous agreement that the time has come to address these concerns in a nonpartisan manner. Thus, we urge that a consulting firm be commissioned to produce recommendations to bring our emergency system up to first-class standards. We understand that such a study would involve some significant one-time costs, but we believe that those would pale in comparison to likely savings in all sectors. And most importantly, the people of San Francisco, our patients, would benefit most of all.

Thank you for your consideration, Richard Podolin, MD, SFMS President; Steve Heilig, MPH, Director, Public Health and Education/ Past-President, San Francisco Emergency Physicians Association

SAN FRANCISCO MEDICINE SEPTEMBER 2016 WWW.SFMS.ORG

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74512 (9/16) Copyright 2016 Mercer LLC. All rights reserved.

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

OR SCAN TO! LEARN MORE!

San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

Find the best specialist for your patient with one call.

We make it easy to transfer and refer your patients to specialists at CPMC, part of the Sutter Health network. One call allows you to match your patients’ needs with the right specialist, notify admissions, get authorizations and more.

And we’re available 24/7, so you never have to wait to find the best possible care for your patients.

Referrals and Transfers 24/7 888-637-2762 cpmc.org