official publication of the san diego county medical society April 2009

Health
information
technology

SDCMS and ama candidate statements P.16

Polst form now available in california P.20
Interview with kindred hospital ceo P.22
hero for a day P.44

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 Contents VOL. 96 | NO. 4

30
Health Information
Technology
Electronic Health Record Buyers, Beware
SDCMS E-prescribing Resources
AMA Explains the ARRAs HIT Provisions
HIT Stimulus Could Bring $3 Billion in New Funds to California
The Infobutton: Knowledge-based System Meets EHR
Electronic Records Would Improve Americans Health (Web Exclusive)
The Internet: Friend or Foe to Physicians? (Web Exclusive)

[Departments]

4 Contributors
This Issues Contributing Writers 22 Interview
With Kindred Hospital CEO Natalie Germuska

6 Editors Column
The Secret Sauce of Office Practice Redesign
24 County Public Health
Officers Update

8
Place Matters to Your Patients Health

26
SDCMS 2009
Seminars and Events Technology matters

10
Cloud Computing and Healthcare

40
Community
Healthcare Calendar Physician Marketplace

12
Classifieds

41
Ask Your
Physician Advocate Volunteer

16
With SDCMSFs Project Access San Diego

44
SDCMS BOD and AMA delegate
2009 Election Candidate Statements Hero for a Day
Boy Slices His Wrist on His Snowboard

20 Bioethics
Physician Orders for Life-sustaining
Treatment (POLST) Forms

[ w e b e x cl u s i v e ]
The Coming of Age of Phlebology: New Interest in an Old Condition by Nisha Bunke, MD

2 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
More than a healthcare professional, you are a trusted partner in your patients health. So are we.
Beyond providing outpatient diagnostic imaging services, were here to help you improve the health
of your community. How? By becoming, like you, a true and trusted partner in patient care.

And as your partner, well work to improve your patient outcomes as well as satisfaction. That means
helping you diagnose diseases and disorders safely, quickly and accurately, so that you can begin
treatment sooner. We also understand that no two patients are alike. Well help you treat the individual
needs of unique patient populations, including athletes and the physically disabled. Along with prompt,
patient-friendly customer service, we also provide conveniencewith 15 San Diego area locations and
contracts with most insurance companies. Making it easier for your patients to get the care they need.
From the professionals they trust.

So heres to your patients health. And to the start of a long and healthy partnership.
Contact Imaging Healthcare Specialists today.
 Contributors
AMERICAN MEDICAL ASSOCIATION (AMA) AMAs mission is to pro-
mote the art and science of medicine and the betterment of public
health. Its core values include leadership, excellence, integrity, and
ethical behavior. Its vision is to be an essential part of the professional
life of every physician. AMA helps doctors help patients by uniting phy-
sicians nationwide to work on the most important professional and
public health issues.
RICHARD A. BROWN, MD Dr. Brown, SDCMS and CMA member since
1993, is board certified in both surgery of the hand and orthopedic
surgery. He is a member of Torrey Pines Orthopaedic Medical Group,
Inc.
Marisol Gonzalez Ms. Gonzalez is your SDCMS physician advo-
cate. She can be reached at (858) 300-2783 or at MGonzalez@SDC-
MS.org with any questions you may have about your practice or your
membership.
Joseph E. Scherger, MD, MPH Dr. Scherger, SDCMS and CMA
member since 1993, is clinical professor of family medicine at UC San
Diego. He is also medical director of AmeriChoice, which administers
San Diego County Medical Services. Dr. Scherger, along with editing
San Diego Physician, is chair of the SDCMS Communications Commit-
tee.

Ofer Shimrat Mr. Shimrat is founder and CEO of SDCMS-endorsed

CALIFORNIA HEALTHCARE FOUNDATION The California HealthCare
Foundation (CHCF) is an independent philanthropy committed to im-
proving the way healthcare is delivered and financed in California. By
promoting innovations in care and broader access to information, CH-
CFs goal is to ensure that all Californians can get the care they need,
when they need it, at a price they can afford.
Soundoff Computing Corporation, a consultancy specializing in IT
products and services. Originally an applications developer, he brings
database methodology approaches to network implementations. He
combines practical experience as a thrice business owner with best
practices in providing organizations with needs analysis, business lo-
gistics, IT infrastructure, and proactive maintenance. Visit Soundoff-
Computing.com or call (858) 569-0300.

Stephen H. Carson, MD Dr. Carson, SDCMS and CMA member

since 1983, has for the past 25 years served as a consultant for health
systems, schools of medicine, health plans, hospitals, and medical
groups. In 1992, Dr. Carson founded Primary Care Associates (PCA), an
independent practice association of 80 primary care physicians and
more than 300 specialists serving the north coastal region of San Di-
ego County. Dr. Carson served as the chief medical officer for the San
Diego County Medical Society Foundation from 2005 through 2008.
He continues to practice pediatrics and pediatric pulmonary medicine
in Hillcrest.
Lynette Cederquist, MD Dr. Cederquist, SDCMS and CMA mem-
ber since 2005, co-chairs SDCMS Bioethics Commission.
Lauren Wendler Ms. Wendler is your office managers SDCMS of-
fice manager advocate and can be reached at (858) 300-2782 or at
LWendler@SDCMS.org.
Wilma J. Wooten, MD, MPH Dr. Wooten, SDCMS and CMA member
since 2006, is the public health officer for the County of San Diego,
Health and Human Services Agency. She is board certified in family
medicine and has a masters degree in public health. From 1990 to
2001, she practiced medicine as a faculty member in the UCSD De-
partment of Family and Preventive Medicine; she joined the County of
San Diego in April 2001. Dr. Wooten remains a UCSD volunteer associ-
ate clinical professor and is an adjunct professor at SDSUs Graduate
School of Public Health.

Send your letters to the editor to Editor@SDCMS.org

East County Director William Tseng, MD SDCMS EXECUTIVE COMMITTEE

Woody Zeidman, MD
Hillcrest Director Roneet Lev, MD PRESIDENT Stuart Cohen, MD, MPH
Thomas McAfee, MD president-elect Lisa Miller, MD
Kearny Mesa Director Adam Dorin, MD past president Albert Ray, MD
Sherry Franklin, MD secretary Robert Wailes, MD
EDITOR Joseph Scherger, MD, MPH La Jolla Director Steven Poceta, MD treasurer Susan Kaweski, MD
MANAGING EDITOR Kyle Lewis Wayne Sun, MD COMM. CHAIR Joseph Scherger, MD, MPH
North County Director James Schultz, MD DELEGATIONCHAIR Jeffrey Leach, MD
Douglas Fenton, MD Board REP. Sherry Franklin, MD
editorial board Van Cheng, MD
Arthur Blain, MD Board REP. Robert Peters, PhD, MD
Adam Dorin, MD South Bay Director Vimal Nanavati, MD LEGIslative chair Robert Hertzka, MD
Robert Peters, PhD, MD Anna Seydel, MD executive director Tom Gehring
David Priver, MD At-large Director Jeffrey Leach, MD
SDCMS cma trustees Theodore Mazer, MD
Robert Peters, PhD, MD
Roderick Rapier, MD Albert Ray, MD
David Priver, MD
Joseph Scherger, MD, MPH Robert Wailes, MD
Wayne Iverson, MD
Paul Kater, MD OTHER cma trustees Catherine Moore, MD
MARKETING & John Allen, MD Diana Shiba, MD
Kevin Malone, MD
PRODUCTION manager Jennifer Rohr ama delegates James Hay, MD
Young Physician Director Mihir Parikh, MD
Sales Director Dari Pebdani Resident physician director Kimberly Lovett, MD Robert Hertzka, MD
PROJECT DESIGNER Lisa Williams Retired Physician director Glenn Kellogg, MD alternate delegate Albert Ray, MD
COPY EDITOR Adam Elder MEDICAL Student Director Geraldine Kang Lisa Miller, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and
length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego
Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address
all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to cpinfo@sandiegomag.com. San Diego Physician is published monthly on the first of the month.
Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

4 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
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A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 5
 Editors Column
By Joseph E. Scherger, MD, MPH

The Secret T his issue marks the third

year for devoting an issue to
health information technol-

Sauce of
ogy (HIT). Computer applications have
already changed front-office procedures,
and their clinical applications are spread-

Office Practice
ing to change the face of medical practice.
The computer with an EHR is becoming
the third person in the exam room. In-

Redesign
creasingly, that computer contains not
just the patients health record but rapid
access to all medical knowledge.
2009 may go down in history as the
year of healthcare reform in America. If

Making the Process of Care Continuous Rather
Than Episodic Being Proactive With Care Rather
Than Reactive Activating Patients for Greater
Self-management
not, it certainly will be the start of major
change. The current wasteful and ineffi-
cient non-systems of care are not sustain-
able. We need methods that are better,
faster, and cheaper the dream of any
redesign engineer.

6 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
 The imperative of healthcare redesign
for today is to achieve a combination of
cost reduction, quality improvement, and
service improvement. All that is possible
today with HIT applications and new
methods of care. Major change has hap-
pened in most other service industries
and will happen to us in medical office
practice. Secure online communication
with patients, even automatic communi-
cations for things like making appoint-
ments and refilling some prescriptions, is
just one of the many efficiencies that HIT
will bring to office practice to improve
service and lower costs.
Besides using Internet communica-
tions, how do we improve the quality of
outcomes and improve service while low-
ering the cost of care? Current office prac-
tice is reactive, episodic, and physician-
dependent. Our workday has us reacting
to whatever is on our schedule and what-
ever urgencies arise. Our care is delivered
episodically during office visits. As physi-
cians, we carry the major responsibility of
providing the totality of medical care to
our patients. We are in charge of ensuring
that our patients get all the preventive ser-
vices, chronic illness care, and acute care
they need. As medical knowledge grows,
this responsibility becomes overwhelm-
ing. New methods of care are needed.
The imperative
of healthcare
redesign for today
is to achieve a
combination of cost
reduction, quality
improvement,
and service
improvement.
Despite our best efforts, traditional
office practice results in only about 25
percent of our patients getting all their
recommended services or having their
outcomes of chronic illness care at the
target levels. It is easy for us to say that
the responsibility for these gaps is on the
patient. If they just came in regularly and
complied with all our care, many more
would be at target. While this is true,
there are emerging models of care that
are achieving much better outcomes.
Demonstration projects of chronic ill-
ness care have shown that working dif-
ferently may result in improved quality of
care at lower cost. There is a secret sauce
of care strategies that, when combined,
has a major impact on the outcomes of
care to a population of patients. The three
ingredients to this secret sauce are:
making the process of care continuous
rather than episodic; being proactive with
care rather than reactive; and activating
patients for greater self-management.
While these three strategies can be done
without HIT, using HIT makes them
much more efficient and begins to move
healthcare into modern processes much
like other service industries today (bank-
ing, travel, accounting, etc.).
Despite our best
efforts, traditional
office practice
results in only
about 25 percent
of our patients
getting all their
recommended
services or having
their outcomes of
chronic illness care
at the target levels.
An online platform of communication
and care services makes the access to care
continuous for patients. They may log
into their personal medical home any-
time, have access to their medical record,
and participate in whatever care services
that are available. The online platform
allows both sides of the care equation
the physician team and the patient to
communicate around care at any time
asynchronously at mutual convenience.
Once a practice has a registry of all its
patients and is able to stratify patients
by age, sex, preventive services, and any
given disease, proactive strategies of care
may follow. If you want to know how your
patients with diabetes are doing, turn
on the computer application and look.
Rather than spending the day reacting to
the patients who are on your schedule,
you and your care team may embark on
productive interactions with patients to
improve their care. With better informa-
A p r i l 2 0 0 9
tion systems, care to a population of pa-
tients may become strategic. Of course
the finances must support this proactive
care and reward better outcomes. That
is where pay-for-performance, or, better
stated, payment for results, replaces pay-
ment for just doing care.
Once patients get their medical records
and are linked into us as their providers of
care, why not let them take a greater role
in their own care? We know what preven-
tive services we want our patients to have;
why not let them obtain them directly?
The experience over the past decade of
studying patient self-management shows
that the more the patients are involved in
their own care, the better the outcomes.
Conversely, the more the patients remain
totally dependent on the physician to pro-
vide all the care, the worse the outcomes.
The tools of HIT do not improve health-
care without the right applications. HIT is
not the answer. People using HIT wisely
have the potential to redesign care for
the better. HIT creates new processes of
care that offer the potential to greatly im-
There is a secret
sauce of care
strategies that, when
combined, has a
major impact on the
outcomes of care
to a population of
patients.
prove the outcomes of care. The financ-
ing of care is moving toward improved
outcomes to a population of care. All
physicians may begin to apply the secret
sauce concepts to improve quality and
service at lower costs. What an exciting
time to be in medical practice.
About the A u t ho r : Dr.
Scherger, SDCMS and CMA member
since 1993, is clinical professor of fam-
ily medicine at UC San Diego. He is also
medical director of AmeriChoice, which
administers San Diego County Medical
Services. Dr. Scherger, along with editing
San Diego Physician, is chair of the SDC-
MS Communications Committee.
| S A N D I E G O P H Y S I C I A N . o r g 7
 SDCMS Members-only Benefits

2009 April
16 Thursday
Seminars and Events
24 Wednesday
2:00PM6:00PM
CMA Contracting Seminar/We-
Free to Member
Physicians and
Their Office Staff!
SDCMS strives to build a robust sched-
ule of free seminars and events for our
member physicians and their office
staffs. All SDCMS member physicians
9:00AM1:00PM
Practice Management binar: Taking Charge: Steps to and their office staffs attend SDCMS
Seminar/Webinar Evaluating Relationships and seminars free of charge (including
(Office Managers Forum) Preparing for Negotiations Office Managers Forums). Our semi-
A Focus on Payor Contracting nars cover a broad range of practice
18 Saturday management topics, including legal
8:25AM3:30PM 25 Thursday issues, HIPAA, risk-management is-
Resident and New Physician 9:00AM2:00PM sues, contract negotiations, and more.
Seminar: Preparing to Practice: CMA Reimbursement Seminar/
For further information about any of
What You Need to Know BEFORE Webinar (Office Managers Forum):
these seminars and events, watch your
You Begin Your Practice Back to Basics: A Step-by-Step
emails and faxes, visit SDCMS web-
Guide to Maximizing Your Cash
Flow site at SDCMS.org, or contact Lauren
22 Wednesday Wendler at (858) 300-2782 or at LWen-
6:30PM8:00PM dler@SDCMS.org.
Risk Management Seminar/Webi- July
nar: How to Handle Legal Notices 22 Wednesday
(Summons, NOI, Subpoenas) 6:30PM7:30PM
Risk Management Webinar:
23 Thursday Who Can Be Told What? (Commu-
11:30AM1:00PM nicating in a HIPAA World)
Watch
Previous
Risk Management Seminar/Webi-
nar: How to Handle Legal Notices 23 Thursday
(Summons, NOI, Subpoenas) 11:30AM12:30PM
Risk Management Webinar: SDCMS
29 Wednesday Who Can Be Told What? (Commu-
Seminars
Online Now!
11:30AM1:00PM nicating in a HIPAA World)
Medi-Cal Billing Seminar/Webinar
August
May 12 Wednesday Available to Members
7 Thursday 11:30AM1:00PM at SDCMS.org
9:00AM12:30PM OSHA Updates Seminar/Webinar
EMR Road Show (Office Managers Forum) SDCMS Member Physicians and Staff:
(Office Managers Forum) Dont forget that you can view all previ-
October ous SDCMS seminars online whenev-
20 Wednesday 14 Wednesday er you like. To locate a previously held
11:30AM1:00PM 6:30PM8:00PM seminar for viewing, simply go to SD-
Billing Seminar/Webinar Financial Issues Seminar/Webinar CMS.org and do a search in the search
(Office Managers Forum) (Including Estate Planning) field on the homepage. For assistance
in locating a seminar or in logging into
June 15 Thursday SDCMS website, please contact Kyle
18 Thursday 11:30AM1:00PM Lewis at (858) 300-2784 or at KLewis@
11:30AM1:00PM Financial Issues Seminar/Webinar SDCMS.org. All SDCMS seminars are
Legal Seminar/Webinar (Office Managers Forum) made available for viewing online with-
(Office Managers Forum) in 24 hours of their date of occurrence.
Thank you for your membership!

8 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 9
 Community Healthcare Calendar
Advances in the Neuropsychological
To submit a Assesment and Treatment of
community School-age Children with
Cognitive Deficits
healthcare event Presentation of the latest findings on
the assessment and remediation of
for possible magazine cognitive and behavioral impairments
and website in school-age children. April 29 at the
Hilton San Diego Resort. Visit http://
publication, email cme.ucsd.edu/neuro.
KLewis@SDCMS.org. 14th Annual Primary Care
in Paradise
All events should be Will assess current trends in preventive
physician-focused healthcare with an emphasis on
endocrinology, orthopedics, obesity,
and should take migraines, COPD, melanoma, and sleep
apnea; summarize recent developments
place in San Diego and changes in the treatment of
County. disease processes likely to be seen in
the primary care office setting; and
identify and treat problems commonly
encountered in primary care clinical
practice. April 69 at the Hapuna
Beach Prince Hotel, Big Island, Hawaii.
Contact (858) 652-5400 or med.edu@
scrippshealth.org.
Fresh Starts Surgery Weekend
A team of dedicated medical volunteers
donates their time and expertise to
provide disadvantaged children with the
highest quality medical services and
ongoing care. April 1819, June 1314,
July 2526, September
1213, and November 78 at
the Center for Surgery of
Encinitas. Contact (760)
448-2021 or mimi@
freshstart.org, or visit
www.freshstart.org.
2nd Annual Sudden
Cardiac Arrest
April 2526 at the
Hilton San Diego
Resort. Visit www.
scripps.org/health-
education.
10 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
American Occupational Health
Conference 2009
Topics include occupational medicine/
research, infectious disease, toxicology,
workers compensation, ergonomics,
and environmental pollution. April
2629 at the Manchester Hyatt Hotel in
San Diego. Visit www.acoem.org.
San Diego Psychiatric Society
50th Annual Installation Event and
Psychiatric Symposium
May 3 6:00pm-9:30pm. Contact Karen
Mitrovich-Dotson at (858) 279-4586 or
at KDotson@SDCMS.org.
Essential Topics In Pediatrics 2009
May 14-15 at the Catamaran Resort Hotel.
Visit http://cme.ucsd.edu/events.cfm.
Integrative Holistic Nursing
Conference: Bringing Healing
to You and Your Patients
May 1516 at the Paradise Point Resort,
San Diego. Contact (858) 652-5400
or med.edu@scrippshealth.org or visit
www.scrippsintegrativemedicine.org.
2009 American Thoracic Society
International Conference
Educational program for clinicians
and researchers in adult and pediatric
pulmonary, critical care, and sleep
medicine. Sample a broad spectrum
of topics or concentrate on critical
care, sleep, allergy/immunology,
or other specialty related to
respiratory medicine. May 1520.
Visit www.thoracic.org.
Alzheimers Disease: Update
On Research, Treatment, and Care
May 2122 at the Omni San Diego Hotel.
Visit http://cme.ucsd.edu/events.cfm.
Riverside County Medical
Association: 5th Annual Cruisin
Thru CME (Eastern Mediterranean)
July 617. Call (800) 745-7545.
20th Annual Coronary Interventions
October 2830 at the Hilton La Jolla
Torrey Pines. Visit www.scripps.org/
health-education.
XVII World Congress of
Psychiatric Genetics
Offers a forum for exchange of the
latest scientific data and education for
the interested clinician. November 48
at the Manchester Grand Hyatt. Contact
(858) 534-3940 or ocme@ucsd.edu.
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 Noted
to Palmettos website at www.palmettogba.
com/J1B and search for the article titled
Medicare Part B Medical Records: Signa-
ture Requirements, Acceptable and Unac-
ceptable Practices.

Q
UESTION: Sometimes my of-
Ask Your fice staff fills out forms on

Physician
our patients behalf. Are there
any steps I should take before I start
charging my patients for the completion

Advocate
of forms?

ANSWER: Yes. You may wish to consider

reviewing all managed care contracts to
see whether there are any restrictions.
By Marisol Gonzalez Some contracts may only allow you to bill
patients for co-pays and deductibles. This
may be interpreted as a prohibition against
charging for forms. Contact your payers.
You may want to let them know you plan
to institute a charge for form completion
and avoid problems down the road. Also,
notify your patients ahead of time. This
will avoid surprises and hard feelings. Of-
fice staff should be briefed on exactly how
to respond when patients question the
Palmetto Denials Filling Out Forms for Patients Enrolling in Medicare need for the fees or ask whether the fee
can be waived.

of service beginning with September 3,
Your 2007), have new signature requirements.
Medicare requires the individual who
Physician ordered/provided services to be clearly
Advocate identified in the medical records. The sig-
nature for each entry must be legible and
Has the should include the first and last name of
Answers! the practitioner. For clarification purposes,
Palmetto recommends you include your
applicable credentials, e.g., PA, DO, or
Q
UESTION: I am a brand-new
physician to Medicare. How do
I enroll?
ANSWER: If you are new to Medicare and
you are going to fill out an 855I or 855R
application, you can now do this online at
www.cms.hhs.gov/medicareprovidersu-
penroll. However, if you need to change

Q
UESTION: I have sent three
appeals to Palmetto that have
been denied. I also sent opera-
tive reports along with the appeals. The
explanation of their decision states that
there are acceptable methods of sign-
ing records/test orders and findings.
What does this mean?
ANSWER: Claims processed by Palmetto
GBA on or after April 28, 2008 (for dates
MD. The purpose of a rendering/treating/
ordering practitioners signature in pa-
tients medical records, operative reports,
orders, test findings, etc., is to demon-
strate that the Part B services have been ac-
curately and fully documented, reviewed,
and authenticated. Furthermore, it con-
firms that the physician has certified the
medical necessity and reasonableness for
the service(s) submitted to the Medicare
program for payment consideration. For
more information on this topic, please go
from a solo proprietor to a solo incorpo-
rated physician, you must still do this via
paper. The link above can currently only
be used for new providers and reporting
other practice changes.
A b o u t t h e A u t ho r : Ms. Gon-
zalez is your SDCMS physician advocate.
She can be reached at (858) 300-2783 or at
MGonzalez@SDCMS.org with any ques-
tions you may have about your practice or
your membership.

Does Your Office Manager Have a Question Too?

Lauren Wendler, your SDCMS office manager advocate, is on staff and ready
to help your office manager with any questions he or she may have. Feel free
to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help.

12 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
 Please Welcome
SDCMS
New and Rejoining Members
Welcome
New Members
Raghava Rao Gollapudi, MD
Internal Medicine,
Cardiovascular Disease, Welcome
and Interventional Cardiology
San Diego
(858) 244-6800
Richard Keitley Gundry, MD
Internal Medicine
Ramona
(760) 789-8431
Website Snapshot
T
he Medpedia Project is a
long-term, worldwide proj-
ect to evolve a new model
for sharing and advancing knowledge
about health, medicine, and the body
among medical professionals and the
general public. This model is founded
on providing a free, online technology
platform that is collaborative, interdis-
ciplinary, and transparent. Users of
the platform include physicians, con-
sumers, medical and scientific jour-
nals, medical schools, research insti-
tutes, medical associations, hospitals,
for-profit and nonprofit organizations,
expert patients, policy makers, stu-
dents, nonprofessionals taking care of
loved ones, individual medical profes-
Note: Text Taken From the Medpedia Website
Timothy Michael Strouse II, MD
Internal Medicine
Chula Vista
(858) 499-2707
Rejoining Member
Stephen H. Miller, MD
Plastic Surgery and Surgery
San Diego
(619) 543-6770
The Medpedia
Project
Medpedia.com
sionals, scientists, etc. As Medpedia
grows, it will become a repository of
up-to-date, unbiased medical informa-
tion, contributed and maintained by
health experts around the world, and
freely available to everyone. In asso-
ciation with Harvard Medical School,
Stanford School of Medicine, Berkeley
School of Public Health, University of
Michigan Medical School, and other
global health organizations, Medpedia
will be a commons for the gathering
of the information and people critical
to healthcare. Version 1.0 of the online
Medpedia platform was released in
beta on February 17, 2009. Only phy-
sicians and PhDs are allowed to edit
the articles on Medpedia after they
create an account and are approved as
an editor. Non-editors can create an ac-
count and then suggest changes that
must be approved by an editor before
going live on the site. Visit Medpedia.
com for more information.
A p r i l 2 0 0 9
Get in
Touch
Your SDCMS Support
Team Is Here to Help!
Address: 5575 Ruffin Rd., Ste. 250,
San Diego, CA 92123
Telephone: Dareen Nasser, office
manager, at (858) 565-8888 or at
DNasser@SDCMS.org
Fax: (858) 569-1334
CEO/Executive Director:
Tom Gehring at (858) 565-8597
or at Gehring@SDCMS.org
COO/CFO: James Beaubeaux
at (858) 300-2788 or at
Beaubeaux@SDCMS.org
Director of Membership
Development: Janet Lockett
at (858) 300-2778 or at
JLockett@SDCMS.org
Director of membership
Operations and Physician
Advocate: Marisol Gonzalez at
(858) 300-2783 or at MGonzalez@
SDCMS.org
Office Manager Advocate:
Lauren Wendler at (858) 300-2782
or at LWendler@SDCMS.org
Director of Engagement:
Jennipher Ohmstede at (858) 300-
2781 or at JOhmstede@SDCMS.org
sdcms foundation executive
director: Kitty Bailey at (858)
300-2780or at KBailey@SDCMS.org
sdcms foundation associate
executive director:
Tana Lorah at (858) 300-2779
or at TLorah@SDCMS.org
Director of Communications
and Marketing: Kyle Lewis at
(858) 300-2784 or at KLewis@
SDCMS.org
Specialty society advocate:
Karen Dotsonat (858) 300-2787 or at
KDotson@SDCMS.org
Letters to the Editor:
Editor@SDCMS.org
General Suggestions:
SuggestionBox@SDCMS.org
| S A N D I E G O P H Y S I C I A N . o r g 13
 Noted

CMA Advises MDs to

Begin EHR Needs
Assessment Process Now
Visit CMAs HIT Resource Center at CMANet.org/HIT
Physicians:
Get
Noticed! T he 2009 federal economic stim-
ulus package includes $19 billion
for health information technol-
ogy (HIT), the vast majority of which will
be directed to physicians to subsidize the
cess of assessing their EHR needs, with an
eye on what will work best for their spe-
cialties, the sizes of their practices, their
career stages, and their comfort levels with
technology.
Wish Your Legislators purchase and usage of electronic health
record (EHR) systems. Beginning in 2011,
Because of the complexity and cost in-
volved with selecting and implementing
a Happy Birthday! qualifying Medicare providers stand to an EHR, it is imperative that physician
Let your legislators know that youre gain up to $44,000 under the program; practices plan accordingly. To help, CMA
watching and that you vote send them qualifying Medi-Cal providers stand to re- has created an HIT Resource Center
a birthday card this month! ceive as much as $64,000. CMANet.org/HIT where you will find
Many of the standards governing the the latest information, answers to fre-
Congresswoman Susan Davis subsidies will be worked out in the com- quently asked questions, and links to HIT-
4305 University Ave., Ste. 515 ing months. Given the lack of clarity about related resources for physicians.
San Diego, CA 92105 what EHR systems will qualify a physician CMA is closely monitoring the HIT
Telephone: (619) 280-5353 to receive the federal subsidy, CMA be- standards development process and will
Fax: (619) 280-5311 lieves that now is not the time to rush out be updating the resource center as new in-
Email (via website): and purchase a system. In the meantime, formation becomes available.
http://www.house.gov/ CMA advises physicians to begin the pro-
susandavis/contact.shtml
Birthday: April 13

14 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
Merchant Services:
Credit/Debit Card Processing
Potential Value: $1,500 for
high-dollar, high-volume cost!
Chase Paymentech provides
member physicians fast, secure,
and cheaper credit card payment
processing, excellent customer
service, and innovative payment
options. SDCMS members
receive upgraded customer
service, free online reporting,
and a guaranteed 1020 percent
savings from current costs. Let
Chase Paymentech provide you
with a competitive quote today
by sending three months of
merchant statements to Janet
Lockett at JLockett@SDCMS.org,
by fax to (858) 569-1334, or call
her at (858) 300-2778.
Technology Solutions
Potential Value: $1,000!
Soundoff Computing
Corporation provides best-
of-breed hardware, software,
and network technologies
for your medical practice,
utilizing best practices for all
aspects of IT implementations.
SDCMS member physicians
receive free site inspection
and subsequent infrastructure
recommendations; free inventory
and assessment of network and
hardware computing assets;
free analysis of Internet/telco/
data activity and subsequent ROI
recommendations.To learn more,
visit www.soundoffcomputing.
com or contact Ofer Shimrat
at (858) 569-0300 or at ofer@
soundoffcomputing.com.
Banking Products and Services
Potential Value: $2,500!
Torrey Pines Bank is a low-
maintenance bank that
meets business owners high
expectations while requiring of
them the absolute minimum of
time and effort. Approved SDCMS
members receive no-fee lines of
credit, $1,000 fee discounts on
commercial real estate loans,
waived monthly maintenance
fees on personal accounts for
practice partners and employees
up to $10 per month, free first
order of standard checks for
personal accounts, increased
deposit interest rates, waived
monthly maintenance fee for
business online banking and bill
pay services, ATM fees waived up
to $15 per month, and free courier
service or remote deposit service.
Contact Benjamin Pimentel at
(858) 259-5317 or at bpimentel@
torreypinesbank.com.
Insurance Products and Services
Potential Value: $1,000$2,500!
Alliant Insurance Services, Inc.,
is Californias largest premier
specialty insurance broker and
ranks among the 13 largest in the
nation. SDCMS members receive
discounts on a comprehensive
portfolio of insurance products
and services, including savings of
510 percent or more off of the
cost of insurance, or cash rebates
related to practice size, a savings
of 712 percent on long-term
disability income protection,
and no-cost human resources
consulting. Contact Mark Allan at
(800) 654-4609 or at mallan@
alliantinsurance.com. Visit Alliant
Insurance Services online at www.
alliantinsurance.com.
Tamper-resistant
Prescription Pads
Potential Value: $300!
American Security Rx, which
is a California Department of
Justice and California Board of
Pharmacy approved Security
Printer (SP-9), provides tamper-
resistant California security
prescription forms for controlled
medications. SDCMS members
receive discounts on tamper-
resistant prescription forms.
Contact American Security Rx
at (877) 290-4262 or at info@
americansecurityrx.com. Visit
American Security Rx online at
www.americansecurityrx.com.
Billing Solutions
Potential Value: $1,000!
CHMB Solutions provides
outsourced medical billing,
revenue cycle management
services, information technology
support, and hardware solutions
to physician practices, clinics, and
multi-specialty organizations.
SDCMS members receive a 50
percent discount on startup fees
and a $33 per-physician-per-
month services credit, 10 percent
off of outsourced IT support, 10
percent off of already discounted
Dell hardware solutions, and a
free coding hotline. Contact Ron
Anderson at (760) 520-1340 or at
randerson@chmbsolutions.com.
Email your coding question(s) to
SDCMS at Coding@SDCMS.org.
Visit CHMB Solutions online at
www.chmbsolutions.com.
Contract Analysis
Potential Value: 10 percent
of Net Revenue!
Coastal Healthcare Consulting
Group, Inc., is a specialty
consulting firm that assists clients
with managed care contracting,
contract negotiations,
credentialing, revenue
enhancement, and strategic
planning. SDCMS members
receive a free contracting
analysis, a discount on hourly
rates, and a package price on
services for contract negotiations,
including health plan contracts!
Contact Kim Fenton, president,
at (949) 481-9066 or at
kimf@healthcareconsultant.
A p r i l
org. Visit Coastal Healthcare
Consulting Group online at www.
healthcareconsultant.org. For
consultation scheduling, contact
Marisol Gonzalez, your SDCMS
physician advocate, at (858)
300-2783 or at MGonzalez@
SDCMS.org.
Practice Management Consulting
Potential Value: $1,000$2,500!
Practice Performance Group
(PPG) provides high-performance
medical practice management
services for physicians, including
consulting, expert witness,
workshops, speaking, and a
monthly newsletter. SDCMS
members receive discounted
management consulting on
productivity and patient flow,
personnel, governance and
SDCMS
Endorsed
Partner
Benefits
Total Potential Value to SDCMS Members:
$10,000$17,000
management, market strategy
and tactics, practice acquisitions,
sales and mergers, and a free
one-year subscription to their
newsletter, UnCommon Sense.
PPG also conducts free half-day
seminars for SDCMS members
and their staffs at SDCMS offices.
Contact Jeffrey Denning or Judy
Bee at (858) 459-7878 or at
Jeff@PPGConsulting.com. Visit
PPG at www.PPGConsulting.com.
Professional Liability Insurance
Potential Value: $500$2,500!
The Doctors Company (TDC)
enjoys a reputation as the
industry vanguard for low
California rates, aggressive claims
defense, expert patient safety
programs, superior customer
service, and exemplary member
benefits. Most SDCMS members
are eligible for a 5 percent
discount on insurance premiums
2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g
and a 7.5 percent dividend credit.
To learn more, contact Janet
Lockett at SDCMS at (858) 300-
2778 or at JLockett@SDCMS.
org. Visit TDC online at www.
thedoctors.com.
Collections Services
Potential Value: $350500!
TSC Accounts Receivable
Solutions has provided
personalized, innovative
collection and total accounts
management services since 1992.
This local, family-owned business
management team has combined
experience of more than 50
years in the healthcare billing and
collection field. SDCMS members
receive a 10 percent discount
on monthly charges. Contact
Catherine Sherman at (888) 687-
4240, ext. 14, or at csherman@
tscarsolutions.com. Visit TSC
online at www.tscarsolutions.com.
Accounting Services
Potential Value: $500$2,000!
AKT CPAs and business
consulting LLP has provided
audit, tax preparation and
planning, accounting assistance,
and business consulting to San
Diego County clients for more
than 50 years. SDCMS members
receive a 15 percent discount on
standard rates for professional
services, with an unconditional
satisfaction guarantee: SDCMS
members who are not completely
satisfied with the work AKT
performs for them pay only
what they thought the work was
worth. Contact Ron Mitchell at
(760) 268-0212 or at rmitchell@
aktcpa.com. Visit AKT at www.
aktcpa.com.
15
 SDCMS Membership
Candidate
Statements
For SDCMS Board of Directors and AMA Delegates
President: Lisa Miller, MD
I am honored to assume the position of president of
the San Diego County Medical Society (SDCMS). I look
forward to the challenges ahead, for medicine, for the
delivery of healthcare, and for SDCMS member physi-
cians. SDCMS needs to continue to have a strong voice
in legislative issues locally, statewide, and nationally.
As physicians, we are faced with ever-increasing chal-
lenges to our autonomy to practice medicine, to de-
liver timely and appropriate care to all members of
our community, and to be reimbursed appropriately.
As a medical society, we must maintain a strong mem-
bership base and continue to provide our physicians with valued benefits. I look
forward to the privilege of serving the San Diego County physician community.
Notes: Number in parentheses after name (X) = term length in years. Asterisk after name (*) = incumbent.
Candidate for SDCMS our services, especially when we render emer-
President-elect (unop- gency care outside our contracted plans.
posed): Susan Kaweski, Health information technology will be re-
MD (1) quired of all physicians. The Obama admin-
I am honored to be your istration has said that the goal of HIT is to
candidate for president- reduce costs and guide your doctors deci-
elect. I have served as your sions. If you do not become a meaningful
Kearny Mesa board of di- user, you will face penalties. Dont let our
rectors representative, delegate to the CMA autonomy be lost!
House of Delegates, chairman of the Legis- The trial attorneys are always challenging
lative Committee, member of the Finance MICRA. We are so fortunate in California
Committee, secretary, and most recently as that our malpractice rates are among the low-
treasurer. est in the country, but we need to continually
During these tough economic times, Pres- be vigilant that this will not be taken away
ident Obama wants to provide affordable, because our lawmakers view this as outdated
accessible healthcare for all Americans. We legislation.
have to be at the negotiating table as the deci- These difficult times require strong orga-
sions are being rendered, or other healthcare nization. It is your SDCMS and CMA that
providers will step up to provide cheap care, provide the necessary ammunition to meet
which, in the long range, becomes very costly these challenges and defend your rights. I
for the patient when diagnoses are missed. In look forward to joining you in this mission as
addition, we cannot afford to lose appropri- your president-elect.
ate payment due to grossly unfair Medicare
RBRVS GPCI disparities with San Diego Candidate for
County included in a rural payment area. SDCMS Treasurer
Healthcare plans are increasingly control- (unopposed): Robert
ling our practices. We have to waste time and Wailes, MD (1)
energy on filling out forms and calling them These are very tough times
about nonpayments in return for nominal for just about everybody.
retribution. It is time we get paid fairly for Patients lack good access
16 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
to care, doctors practices are suffering from
too much overhead, and the economy stinks!
I think we can all agree that governmental
overregulation and insurance company bul-
lying are affecting our professional quality of
life. We all have a lot to complain about, and
I think organized medicine is the best way to
look for solutions. One unified voice has the
best chance of successful lobbying for our
patients health and our professional careers.
I have really enjoyed working with SDCMS
at the local and state levels as an advocate
representing the North County medical com-
munity. I would like to bring this experience,
enthusiasm, and optimism for progress for-
ward to be treasurer for the San Diego Coun-
ty Medical Society. I appreciate your support
as well as any input you may have to offer. I
am a firm believer that the more involvement
and brainpower we can recruit, the more our
organization and community as a whole will
benefit.
Candidate for SDCMS
Secretary (unopposed):
Sherry L. Franklin, MD (1)
We are at the forefront of a
significant time of change
in the practice of medicine.
It is now the time to be
sure our voices are heard, our hearts are felt,
our profession is preserved, and our patients
are protected. Partisan politics and the fear
of not being re-elected dictate policy driving
medicine today. My hope is to echo the words
of Dr. Hertzka in saying that physicians are
here to be part of the solution, and add my
own words that we are here to be part of it
on a grand scale. We must sit at the table.
We must be willing and able to negotiate. We
must have the best interest of our practice
and our patients at the forefront of our deci-
sions. I would like all of you to know that I
am the candidate who is ready, willing, and
able to sit at that table. I will fight tirelessly for
your rights, regardless of specialty.
Candidate for SDCMS
Kearny Mesa Geographic
Director #2 (unopposed):
John Lane, MD (2)
Thank you for consider-
ing me for the position of
director on the SDCMS
board. I have been practicing orthopedic
surgery in San Diego since 1990. Through
my fellowship in sports medicine and private
practice, I have had the opportunity to prac-
tice in HMO, solo and small group, as well as
large group settings. This has allowed me to
be in practice settings that have treated man-
aged care, private practice, and workers com-
pensation patients. I believe that these experi-
ences give me a broad perspective regarding
the practice of medicine in our community.
As a physician who takes trauma call, I find
emergency room coverage, balance billing,
and patient access to be issues that need phy-
sician input to provide realistic solutions. I
would be grateful for the opportunity to bring
my experience to the SDCMS board to help
our member physicians maintain successful
practices and provide high-quality care to pa-
tients as we navigate these changing times.
Candidate for SDCMS
East County Geographic
Director #2 (unopposed):
Heywood Woody
Zeidman, MD* (3)
I have been privileged to
represent the San Diego
County Medical Society (SDCMS) at CMA
since 1992. Starting as an alternate, I was
honored to become a full delegate. I have
since become the representative for East
County on the SDCMS board of directors.
However, SDCMS rightly has term limits to
allow for increased involvement of its mem-
bers. This is the last time I can run as the
district representative to the board. I have au-
thored resolutions, on your behalf, accepted
as policy by CMA. I have been a represen-
tative to special sections of both CMA and
AMA. Please allow me the honor to represent
the East County district one last time.
Candidate for SDCMS La
Jolla Geographic Director
#1 (unopposed): Steven
Poceta, MD* (3)
I hope to remain a member
of the San Diego County
Medical Society board of
directors and delegate to the California Medi-
cal Association. I have been an elected board
member representing La Jolla since 2004. I
have been practicing at Scripps Clinic since
1988 and have been a member of SDCMS
and CMA since that time.
I am committed to the fair and open rep-
resentation of our profession to the financial
and political systems in which we operate.
I have tried, since 2004, to bring the voice
of La Jolla physicians to the board and to the
state. I have participated in various training
programs to help me do this in a competent
manner, attended various political events
such as fund-raisers, and kept up with issues
of healthcare reform.
Physicians from my district come from
many types of practices. I am a member of
Scripps Clinic Medical Group, a large multi-
specialty group, where I have served on the
board of directors and been active in a num-
ber of committees. Although a large group
practicing on contract with a foundation,
Scripps Clinic represents a mix of different
practice styles. We are not paid on salary, but
on productivity. Much of each of our suc-
cesses comes from individual relationships
with referring physicians, not from large
HMO contracts. Because of this, I under-
stand some of the problems and issues that
physicians face in small and solo practice.
Scripps Clinic also has an academic model of
practice where research and teaching in our
residency program and fellowship programs
are encouraged. In this regard, Scripps Clinic
operates as an academic model, pooling rev-
enue prior to distribution. We have practiced
capitated medicine as a major model (and
still have a small number of such contracts).
I understand some of the primary care/spe-
cialist differences. Lastly, as we have grown
larger, we initiate physician benefits such as
retirement plans, reminding me of several of
our physicians who have left to work at Kaiser
for just such benefits. I recognize the differ-
ences that physicians have on some of these
issues, especially electronic medical records
and pay-for-performance.
I hope to continue to bring these back-
ground perspectives to the upcoming issues
facing medicine in the coming few years.
I support current CMA and AMA policy
guidelines on healthcare reform, whatever
the ultimate form this takes. Basic principles
include an individual mandate, regulation
of any private insurance element to enforce
community-rating mechanisms, a govern-
ment safety net, and physician autonomy
from regulation and employment by govern-
ment or hospital where feasible. I personally
think that a government-sponsored universal
healthcare system is not practical or desir-
able. However, if our society decides that this
is the best way to make our countrys health
strong, I will fight within that system for ad-
equate physician autonomy, the relationship
with the patient, adequate reimbursement,
and freedom from burdensome regulation.
Should we choose to strengthen and enhance
our system of employee-based healthcare in-
surance, we need to improve regulation on
the insurance industry and devise a mecha-
nism for universal coverage or near-universal
coverage. Lastly, we need to stop the upcom-
ing Medicare cuts and reform the GPCI sys-
tem to ensure stability and do it this year.
Please support my candidacy for SDCMS
directorship.
A p r i l 2 0 0 9
Candidate for SDCMS
North County
Geographic Director #1
(unopposed): James
Schultz, MD* (3)
Thank you for your con-
sideration for membership
on the SDCMS board. I have been a family
medicine specialist in Escondido since 1988.
I have a broad range of clinical and adminis-
trative experience, and continue to be active
clinically in the outpatient setting and in the
inpatient setting as a part-time hospitalist
at Palomar. I have had the honor to serve in
various administrative roles as well, includ-
ing as medical director of a larger private
practice group and currently as the CMO
for a group of Community Health Centers. I
will, if elected, bring a unique perspective to
the board, that of a frontline physician in the
safety-net world who has also lived the lead-
ing (bleeding) edge of managed care. The
Community Health Centers take care of hun-
dreds of thousands of patients and deal with
resource limitations and scarcity of available
services on a daily basis. We and our patients
are among those most at the mercy of the
whims of local, state, and federal policy, yet
traditionally have not been represented in
SDCMS.
Candidate for SDCMS
North County Geographic
Director #2 (unopposed):
Arthur Tony Blain, MD,
MBA* (3)
It is a privilege and an hon-
or to be a candidate for reelection to the posi-
tion of SDCMS North County director. I am
a family practice physician and faculty at the
Naval Hospital Camp Pendleton Family Prac-
tice Residency. In both my current position on
the board of directors for SDCMS and, when
I was a resident, as president of the California
Medical Association Residents and Fellows
Section, I have had the opportunity to see first-
hand the challenges facing medicine region-
ally and nationally, such as medical coverage
for the uninsured, malpractice reform, reim-
bursement, access to care, and healthcare re-
form. The only way to protect and improve our
profession is for physicians to serve in politi-
cal, leadership, and organized medicine roles.
I feel a deep debt of gratitude for those who
have served in organized medicine before me,
and serving as an SDCMS director is my way
to contribute in a proactive way to support and
improve our profession.
Candidate for SDCMS
East County Geographic
Alternate Director (unop-
posed): Venu Prabaker,
MD* (3)
| S A N D I E G O P H Y S I C I A N . o r g 17
 Candidate for SDCMS
Hillcrest Geographic
Alternate Director (unop-
posed): Eric Yu, MD* (3)
Candidate for SDCMS
North County Geographic
Alternate Director (unop-
posed): Steven Green,
MD* (3)
I am honored to be a can-
didate for SDCMS North
County alternate director. I am a family
physician, practicing with Sharp Rees-Stealy
Medical Group in Mira Mesa for the past 20
years. Ive participated in the CMA House
of Delegates through the specialty delega-
tion for the last several years. Given the dif-
ficult economic times we find ourselves in,
it is more important than ever for San Diego
County physicians to focus on our common
ground and work together. Government is
taking a more active role in areas like univer-
sal healthcare access, and nonparticipation in
any such effort is not really an option.
Candidate for SDCMS
La Jolla Geographic
Alternate Director (unop-
posed): Matt Hom, MD (2)
U.S. medicine is at a cross-
roads. With healthcare
reform at the front of the
presidents agenda, I feel
that physician participation in the process
will be critical to ensuring that physicians
are properly represented moving forward.
As an internist in private practice caring for
patients on several outpatient and inpatient
levels, my experience provides me a breadth
and perspective on the dynamics and issues
that confront medicine today.
Candidate for SDCMS
At-large Director #2 (un-
opposed): Robert Peters,
MD, PhD* (3)
I have had the privilege
to represent physicians of
San Diego County for the
last three years. During
this time I have been a delegate to the CMA
House of Delegates, chaired Reference Com-
mittee E on Quality, Ethics, and Legal Affairs,
and serve on CMAs Council on Ethical and
Legal Affairs. Currently, I am your board of
directors representative to the SDCMS Ex-
ecutive Committee. I want to continue my
active involvement in organized medicine
and seek your support for reelection. The San
Diego County Medical Society has a rich his-
18 S A N D I E G O P H Y S I C I A N . o r g
tory as a leader in both local and state issues.
More than ever these issues will have a pro-
found impact on the quality of your practice
and that of your patients lives. These issues
include the protection of MICRA, scope of
practice, reimbursement, access to and qual-
ity of care, information technologies, and sat-
isfaction of practicing medicine. If reelected,
I will proudly serve as your advocate, solicit
your input, and seek solutions to the issues
that are germane to your mode of practice.
Candidates for SDCMS At-large
Director #4:
David E.J. Bazzo, MD (3)
I seek the privilege to rep-
resent San Diego County
physicians as an at-large
director for the San Diego
County Medical Society. I
have a long history of serv-
ing our profession and acting as a physician
advocate. I am currently a clinical professor
in the Department of Family and Preventive
Medicine at the UCSD School of Medicine.
One might ask whether an academic physi-
cian could represent the community of physi-
cians of San Diego County. I will let my past
record speak to this. I have served on the
board of directors for the San Diego Acade-
my of Family Physicians since 2001, serving
as president in 2005. During my time on the
board, I have been fortunate to be involved
in planning educational opportunities for our
membership, and to be involved at the local
and state levels in physician advocacy and
support. I have been selected as one of San
Diegos Top Doctors for the past four years
by my colleagues. This year is a particularly
important year for healthcare. As the new
administration has made healthcare one of
its top priorities and our state budget issues
have forced a hard examination of delivery of
healthcare and its funding, having a voice on
how the future is shaped is paramount. Na-
than Fletcher, our 75th district assemblyman,
is the vice chair of the California Assembly
Committee on Health. Advocacy for the San
Diego County physician will take on extra im-
portance. We need someone who will work
for physicians, and I vow to commit tirelessly
to this service. I seek your support in electing
me as at-large director #4.
Wayne Iverson, MD* (3)
I appreciate the opportu-
nity to serve the medical
community and bring an
extensive background and
experience in my medical
professional activities. I am
a physician in private prac-
| A p r i l 2 0 0 9
tice with offices in La Jolla and Poway. I am a
clinical professor of medicine at UCSD, vol-
unteer faculty, and a fellow of the American
College of Physicians. I served as chairman
of the Graduate Medical Education Commit-
tee at Scripps Memorial Hospital La Jolla.
Also, I served on a CMA task force charged
with acquiring a completely new enterprise
database and association management sys-
tem for CMA. Previously, I was appointed
as a Solo and Small Group Practice CMA
delegate from San Diego County. At the
2006 CMA House of Delegates meeting, I
authored and successfully pushed through
a late emergency resolution calling on CMA
to undertake a national campaign for Medi-
care reform. As an SDCMS director, I will
endeavor to maintain our professional tradi-
tions related to patient care, educating new
physicians, and serving the community. The
changing social environment, economics,
medical technology, and computer technol-
ogy will touch on every aspect of medical
care. With your support, I am confident I can
be a positive factor integrating these changes
into our medical professional culture and at
the same time maintaining our traditions as
physicians.
Candidate for SDCMS
At-large Alternate Direc-
tor #3 (unopposed): Ben
Medina, MD* (3)
Candidate for SDCMS
At-large Director #7
(unopposed): Mihir Parikh,
MD (2)
It is a privilege and an honor
to be a candidate for the po-
sition of at-large director
for SDCMS. I thoroughly
enjoyed learning and participating in the po-
litical process as a young physician director
over the past three years. During this time I
have come to understand the importance and
necessity of having an active medical society
that bridges multiple specialties and multiple
types of physicians. The consensus voice that
emerges from SDCMS becomes our posi-
tion when discussing issues such as access
to healthcare, scope of practice, and quality of
patient care. This voice is very important in
the coming years as healthcare reform gets
under way. I am very interested in continu-
ing to participate in the process of represent-
ing physicians at SDCMS meetings, helping
to formulate organized medicines position,
and then communicating this information
back to the physicians and, of course, the
public. If elected, I will do this to the best of
my ability.
Candidate for SDCMS
At-large Alternate Direc-
tor #6 (unopposed): Alan
Schoengold, MD (2)
I appreciate the opportu-
nity to serve as an at-large
alternate director for SD-
CMS. I have been a mem-
ber of SDCMS for 35 years, and Ive had the
privilege of serving on the boards of a few
IPAs in the past 20 years. As the president
of Sharp Community Medical Group for the
past four years, I have had extensive exposure
to the ongoing development of managed care
in San Diego County. I believe the SDCMS
board will benefit from the experience I will
bring to our local and state medical societies.
I look forward to working with my colleagues
on the board of directors to strengthen the
relationships between our medical leaders in
San Diego County.
Candidate for SDCMS
Young Physician Director
(unopposed): Kimberly
Lovett, MD (1)
I am enthusiastic to repre-
sent the voice of the young
physician on the board
of the San Diego County
Medical Society. I have had the opportunity to
work closely with and learn from many of the
board members and staff at SDCMS over the
past two years. SDCMS and CMA have been
instrumental in developing ideas and provid-
ing education to patients and nonmedical
professionals in the arenas of healthcare re-
form and access to care. I have a passion for
actively participating in the transformation of
our system of medicine, and I believe it can be
done through a collective effort among physi-
cians within organized medicine. I pledge to
represent the interests of young physicians
who will inherit the changes that are occur-
ring today as new legislation is passed at the
city, state, and national levels. I pledge to take
an active role in ensuring that the occupation
we love only grows stronger and more func-
tional for ourselves and our patients.
Candidate for AMA
Delegate (unopposed):
James T. Hay, MD
I have had the privilege
of serving you in many
capacities over the past
24 years, including as the
2001 president of SD-
CMS; the first president
of the SDCMS Foundation; delegate, trustee,
and now speaker of the CMA House of Del-
egates; and delegate of Our AMA. I hope and
expect to become the next CMA president
from San Diego County in 2011.
More important than the titles we accu-
mulate are the accomplishments of your San
Diego County AMA team. The Hertzka, Hay,
Ray, and Miller team is a major influence
within our California delegation to AMA.
This past fall, I wrote and introduced a series
of resolutions that resulted in the adoption by
the AMA HOD of the Principles of the Pa-
tient-centered Medical Home. I was part of
the campaign to elect Bob Hertzka to AMAs
Council on Medical Services. I am chair of
the Finance Committee of the delegation and
helped to reduce expenses for CMA during
these tight budgetary times. I have become
a recognized consensus-building voice in the
AMA House.
Locally, I am proud of the tremendous
growth of SDCMS since we hired CEO Tom
Gehring in 2001; of the Foundation, now an
important part of the charitable community
in San Diego County; of what the Founda-
tions Project Access will do for the under-
served; and of the reorganized governance
structure of SDCMS, begun during my presi-
dential year, that, along with a dynamic CEO
and current leadership, has made San Diego
County the premier county medical society
in California.
We need leaders who build consensus and
can get things done. Certainly, as we face the
challenges of healthcare reform and system
reorganization proposals of the new admin-
istration in Washington, DC, we want people
who understand the policy and the politics. I
am very grateful that you have believed that
I do, and I ask for your support to continue
as your delegate to the AMA House of Del-
egates.
Candidates for AMA Delegate:
Robert E. Hertzka, MD
In these most challeng-
ing of times, I have be-
come the first San Diego
County physician in de-
cades to actually reach
the senior policymaking
ranks of AMA. Last year I
was elected unanimously
by the 475 delegates of
AMA to be one of only nine physicians on
their Council on Medical Service. This Coun-
cil is charged with developing virtually all of
the socioeconomic policy for AMA, and I am
now there to represent the interests of San
Diego Countys physicians.
Times have never been more challenging
for us. While headline after headline high-
A p r i l 2 0 0 9
lights the nations escalating economic woes,
physicians have been economically pounded
for decades. We have had to deal with under-
funded Medicare and Medicaid programs,
unfunded mandates on our cost of practice,
and private health insurers who have been so
abusive in their practices that they were suc-
cessfully sued as racketeers just a few years
ago.
Against these challenges, I have been hon-
ored to aggressively represent the physicians
of San Diego County in various capacities for
nearly 20 years, including as your SDCMS
president in 1999 and your CMA president
in 200405. And I continue to be fully en-
gaged at the local, state, and federal levels
all while maintaining a full-time practice
and teaching two health policy courses at the
UCSD School of Medicine.
Finally, I would note that on the federal
level, in addition to my active participation
on your behalf in AMA affairs, I continue to
travel to Washington, DC, several times each
year to stay in touch with many in Congress,
including our five local representatives. And,
as recently as last summer, I spent two hours
on the phone one morning to convince wa-
vering members of Congress to support re-
versal of a pending Medicare physician pay-
ment cut just as the vote was about to be
taken.
I respectfully ask for your support to be re-
elected as one of your AMA delegates.
Wayne Iverson,
MD, MBA
As a medical stu-
dent at Northwestern
University School of
Medicine, I gained
my academic training
several blocks from
the home offices of
the American Medical
Association in Chicago. My professors were
not only giants in academic medicine but
critically involved in AMA activities. It was at
this early age in my adult life that I gained
undying respect for my fellow physicians and
their ability to work collectively to advance the
medical profession in all its activities. I never
had any doubts that my life as a physician
would have the three integral parts of clinical
patient care, teaching young physicians, and
serving my colleagues in our professional as-
sociations. I first became a member of AMA
in 1978 and believe I have a great deal to offer
as an AMA delegate. It is a privilege to have
my name placed in consideration for AMA
delegate, and I would be honored to receive
your support.
| S A N D I E G O P H Y S I C I A N . o r g 19
 Bioethics
By Lynette Cederquist, MD
Physician
Orders for
Life-sustaining
Treatment
Now Available in California
W hile methods of document-
ing end-of-life wishes have
included advance directives,
preferred intensity of care, and living wills,
an improved option is now available in
California. Physician Orders for Life-sus-
taining Treatment (POLST) is a physician
order form that complements an advance
directive by taking the individuals wishes
20 S A N D I E G O P H Y S I C I A N . o r g
You and your patients can download
the POLST form free of charge at FinalChoices.org.
POLST is particularly useful for persons
who are frail and elderly or who have a
compromised medical condition, a prog-
nosis of one year of life or less, and/or a
terminal illness. It should be executed as
part of the healthcare planning process and
reflect careful decision making by the per-
son and/or their legally recognized health-
care decision maker, in consultation with
their physician, about the patients specific
condition. While the POLST form can be
explained to the patient or his or her repre-
sentative by a healthcare provider such as a
licensed nurse or social worker, questions
about the efficacy or appropriateness of the
treatment options should be deferred to a
POLST is particularly
useful for persons
regarding life-sustaining treatment and
converting them into a medical order.
POLST is designed both to be a statewide
mechanism for an individual to communi-
cate his or her wishes about a range of life-
who are frail and
elderly or who have a
compromised medical
condition, a prognosis
sustaining or resuscitative measures and of one year of life
a portable, authoritative, and immediately
actionable physician order that will be hon- or less, and/or a
ored across treatment settings. terminal illness.
| A p r i l 2 0 0 9
 San Diego Countys
POLST
Implementation
Project
Lynette Cederquist, MD, co-chair
of the San Diego County Medical
Societys Bioethics Commission,
has received a two-year grant
to head up San Diego Countys
POLST Implementation Project.
Under this project, several train-
ers will be educating appropriate
professionals within the commu-
nity, including hospital staffs, se-
nior living facilities, hospices, and
EMS professionals on the proper
use of the POLST document. If
you would like more informa-
tion, have questions, or would like
training at your facility, please
contact the project coordinator,
Karen Mitrovich-Dotson, SDCMS
specialty society advocate, at
KDotson@SDCMS.org or at (858)
300-2787. The 2009 California
POLST form is also available for
download free of charge at Final-
Choices.org.

discussion with his or her physician.

One of the many goals of the POLST
form is to increase the number of pa-
tients who have informed conversations
with their physicians about their end-of-
life preferences, which can be written as
a physicians order and placed in the pa-
tients medical record, thereby increasing
accessibility to the patients goals by medi-
cal staff. As identified in the 2004 RAND
review of the evidence-based literature
published between 1990 and 2007 re-
garding the effectiveness of interventions
is the fact that when using POLST, which
is designed to travel across treatment set-
tings to ensure continuity of care, orders

Do You
regarding CPR in nursing homes were
If you know of any volunteer
universally followed and were honored
opportunities for physicians in

Know of Any
across settings. Residents with a POLST
San Diego County, California,
received more comfort care and were rare-
across the United States, or

Physician
ly transferred to a hospital for life-sustain-
anywhere else in the world,
ing treatment.
please email the information to

Volunteer Editor@SDCMS.org. SDCMS will

publish all physician volunteer
About the A u t ho r : Dr.
Cederquist, SDCMS and CMA member
Opportunities? opportunities free of charge on
our website at SDCMS.org.
since 2005, co-chairs the SDCMS Bioeth-
ics Commission.

A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 21
 Interview
By San Diego Physician

Natalie
Germuska,
RN, MSN
CEO, Kindred Hospital

22 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
Note: This interview is one of an ongoing series of interviews with San Diego County hospital leaders conducted by San Diego Physician magazine.
Neither San Diego Physician magazine nor the San Diego County Medical Society (SDCMS) supports or opposes any views expressed by an indi-
vidual interviewed for the purposes of publication in San Diego Physician magazine.
[The following interview was conducted
on February 5, 2009. Visit SDCMS.org to
read the complete interview transcript.]
San Diego Physician: It looks as if
youre celebrating your 15th anniversary.
Is Kindred a young hospital?
Natalie Germuska: Actually, Kin-
dred has been around for a long time.
Were the only Kindred Hospital in San Di-
ego, but were part of the Southern Califor-
nia District, which is eight hospitals, and
there are 82 long-term acute care (LTAC)
hospitals nationwide.
SDP: How many patients, staff, physi-
cians do you have here?
Germuska: Two hundred staff, thats
roughly what were running right now, and
about 100 physicians on staff its mostly
internal medicine, pulmonary coverage,
but I do have ENT, plastic surgery, vascular
surgery, general surgery, anesthesia. For a
small hospital we actually have all the spe-
cialties on board right now, and that was
something that has evolved over the last
three years. To actually build our census,
in talking with the community, short-term
acute care facilities, and physicians, we re-
alized that we needed to provide the gamut
of services. By having specialists on staff
we are able to provide a higher level of care
than the sub-acute setting and expand the
types of patients we admit. I believe that
specialist coverage has been problematic
with long-term acute cares because were
small; physicians dont want to extend
their practice to us. So its really impor-
tant to get out to the community and show
our outcomes, what we can actually do for
patients, and pulling those types of physi-
cians in to help us care for them. Weve
been very successful with that.
SDP: How many patients?
Germuska: We run a census in the 50s,
and we have 70 licensed beds, 68 opera-
tional. We are busier in the winter months
as this is when the cold and flu season hits
and there are many more medically com-
plex patients requiring prolonged weaning
from mechanical ventilation. At any given
time, 50 percent of our census is patients
weaning from a ventilator. We also have
many patients with infections, so a lot of
them need to be in private rooms. About
half our rooms are private, the others are
semi-private, which sometimes limits ad-
mission capability. We would like to in-
crease our census to 60 on a consistent
basis.
SDP: Do you contract with one medical
group?
Germuska: No, were a melting pot.
Our medical director is a Sharp physi-
cian; hes a triple-boarded pulmonologist,
Dr. Davies Wong, from the Sharp Chest
Medicine Group. And then we have Dr.
Sam Clark, again triple-board-certified in
internal medicine, critical care and pulmo-
nary medicine, who oversees our Critical
Care Unit and Night Physician Program,
and hes actually a Sharp and Scripps phy-
sician. We also have physicians with pri-
mary practices at Scripps Mercy, Paradise
Valley Hospital, Alvarado, and Grossmont
on staff. They all consult and cover for each
other. We are the great melting pot of San
Diego. They share ideas and we are able
to take best practices from the San Diego
area and incorporate them into protocols
and daily practice. Our ventilator-weaning
protocols were influenced by pulmonolo-
gists from Scripps, Sharp, Alvarado, and
UCSD. So we have the best of all minds
working on care initiatives at Kindred.
I believe our positive patient outcomes
speak to these initiatives.
SDP: How do you get the word out
about what you do?
Germuska: The way that we educate
the community and the physicians about
the services that we have is through one-
on-one meetings and group presentations.
We have a team of clinical liaisons; they
have different clinical backgrounds, either
nurses or respiratory therapists, and my-
self, we go out and promote our services.
Were active in the Chamber of Commerce,
a member of the Better Business Bureau,
active in our community, lung and heart as-
A p r i l 2 0 0 9
sociations, and nursing groups. Educating
nurses is one way that we can gain access
to physicians and influence referrals of
patients. We meet with medical directors
of physician organizations, managed-care
payers, and the hospitals. Those folks talk
with their colleagues and link us to physi-
cians who may have patients appropriate
for this level of care.
SDP: Tell our readers about the servic-
es that you provide and how they can
access those services.
Overall, we offer a full range of clinical
services for the medically complex patient,
including intensive care, rehabilitation,
and telemetry/cardiac monitoring. We
have interdisciplinary team rounds and
weekly care conferences that families at-
tend so they are updated on the plan of
care for their loved ones they feel more
involved. As I mentioned earlier, we have
accessibility to many specialists and two
licensed operating rooms, digital radiology
services, and floro capability. Were get-
ting a new multi-site CT scanner onsite in
April. There are a lot of great things that
are happening here, a lot of growth, and I
want people to know that about Kindred.
All a physician needs to do is give us a
call if they want to know more. Well link
them to our director of marketing, one of
our clinical liaisons, or myself. Well come
to the physician, case manager offices, give
them the information they want, and give
them a quick overview of our outcomes. If
they ever have a question about a patient,
they can just call the main number or one
of our liaisons directly, and well go out and
evaluate their patient and let them know if
they meet the criteria.
SDP: Whats the main number?
Germuska: Its (619) 543-4500, and
our admissions office is extension 4265.
Gene Calvert, our admissions coordina-
tor, will contact whomever is appropriate
for patient evaluation. After hours, our
hospital operator will direct the referral to
the clinical liaison on call. We are available
24/7.
| S A N D I E G O P H Y S I C I A N . o r g 23
 County Public Health Officers Update
By Wilma J. Wooten, MD, MPH
Place
Matters
to Your
Patients
Health
Neighborhood Design and Community Resources
W here one lives can affect
health, positively or nega-
tively. Beyond the tradition-
al numbers associated with health, such
as blood sugar and weight, it is well docu-
mented that an individuals address, ZIP
code, and census tract can greatly impact
health equity. An individuals physical ac-
tivity level, eating habits, and other health
behaviors are impacted by the design of
their neighborhood and their access to
community resources, such as transpor-
tation, parks, recreational facilities, and
healthy food outlets. As physicians, you
may make recommendations to your pa-
tients to eat healthy and exercise, but does
their environment support these recom-
mendations? Do they have access to buy-
ing healthy foods or a safe place for rec-
reation?
The Centers for Disease Control and
Prevention (CDC) and the Agency for Toxic
Substances and Disease Registry (ATSDR)
working group describe the social deter-
minants of health as factors in the social
environment that contribute to or detract
from the health of individuals and com-
munities. These factors include, but are
not limited to, socioeconomic status (e.g.,
24 S A N D I E G O P H Y S I C I A N . o r g
education, employment status, income),
transportation, housing, access to services,
discrimination by social grouping (e.g.,
race, gender, class), and social or environ-
mental stressors.
Recent studies show differences in the
medical treatment and outcomes of dif-
ferent racial and ethnic groups. These
differences persist even when comparing
patients of the same gender, condition,
age, income, and insurance. Those with
a higher income have better health out-
comes compared to poorer citizens. Strik-
ing health disparities or health inequities
are associated with higher rates of cancer,
infant mortality, diabetes, and asthma, to
name a few. For example, in San Diego
County the adjusted rates per 100,000
people for diabetes hospitalization in 2007
are 346 for black, 235 for Hispanic, and
100 for white. In comparison, the adjusted
rates for asthma hospitalizations in 2007
were 217 for black, 68 for Hispanic, and 54
for white.
In its Healthy People 2010, the CDC of-
fers two broad health goals for the nation:
increasing the quality and years of healthy
life, and eliminating health disparities/in-
equities. There is also the global movement
| A p r i l 2 0 0 9
sponsored by the World Health Organiza-
tion (WHO) to address health inequity. In
2005, WHO established the Commission
on Social Determinants of Health to review
data and develop programs and policies to
achieve health equity through impacting
the social determinants of health for the
worlds citizens.
Locally, the County Health and Human
Services Agency (HHSA) and community
partners work together to address many
issues of inequities by focusing efforts
on environmental and policy changes. In
December 2008, Public Health Services
sponsored the Unnatural Causes: Place
Matters forum based on the Public Broad-
casting Service (PBS) series that described
the unequal distribution of social, eco-
nomic, and environmental conditions that
impact health, and how communities can
come together to find a solution for these
unnatural causes. The Place Matters
segment identified examples of how where
a person lives can potentially affect their
health, depending on the surrounding
physical, economic, social, and service en-
vironmental factors. For more information
on this compelling series, visit Unnatural-
Causes.org.
 The San Diego County Childhood Obe-
sity Initiative (COI), a countywide public/
private partnership collaboration, was de-
signed to engage community partners to
implement the strategies outlined in the
Call to Action: San Diego County Child-
hood Obesity Action Plan. County super-
visors Pam Slater-Price and Ron Roberts
provided leadership in the creation of the
Obesity Action Plan and the ongoing ef-
forts to work collaboratively with com-
munity partners to address this issue. To
access the plan, visit OurCommunity-
OurKids.org. This comprehensive plan
emphasizes policy and systems changes
that will positively impact the health of San
Diego County children (and their families).
The Action Plan identifies seven domains
where efforts can have the most influence
in shaping healthful environments: gov-
ernments; healthcare systems and provid-
ers; schools, before- and after-school pro-
viders; childcare and preschool providers;
community-based, faith-based, and youth
organizations; media outlets and the mar-
keting industry; and the business domains.
To learn more about these domains, visit
OurCommunityOurKids.org.
Through the COI government domain,
community leaders and key stakeholders
have participated in a forum discussing
environmental design and how the built
environment can support healthy lifestyles.
The Growing Green, Growing Healthy
committee convened a follow-up work-
shop, Healthy General Plans, to discuss
how local county and city planning depart-
ments can integrate health and active living
concepts into long-range general plans.
Planning and public health professionals
across the nation are adopting a new frame-
work for neighborhood design that views
the built environment as an opportunity to
enhance public health. Transportation and
community design factors can increase an
individuals risk of chronic disease, such as
asthma, obesity, and diabetes, in addition
to other adverse health outcomes, includ-
ing pedestrian and motor vehicle injury, as
well as violence. It is well documented that
mitigation of environmental risk factors
within transportation and community de-
sign can have a positive impact on health.
A study conducted during the 1996 Atlanta
Olympics documents that asthma-related
emergency room visits decreased signifi-
cantly (41.6 percent) when traffic was re-
duced and use of public transportation
increased. Research from Saleans and Sal-
lis (2003) demonstrated that residents of a
walkable San Diego neighborhood were
more fit than demographically matched
residents in a less-walkable neighborhood.
Environmental risk factors that contribute
to adverse health outcomes can include
unsafe walking and biking conditions, lack
of access to nutritious foods, poor air qual-
ity, and limited access to opportunities for
daily physical activity. In San Diego County,
several local governmental jurisdictions, in-
cluding Chula Vista, La Mesa, and the City
Beyond the
traditional numbers
associated with
health, such as blood
sugar and weight, it
is well documented
that an individuals
address, ZIP code,
and census tract can
greatly impact health
equity.
and County of San Diego, are incorporat-
ing these public health ideas and language
into planning documents.
The COI healthcare systems and provid-
ers domain surveyed physicians to receive
feedback on the most pressing needs and
strategies to improve their practice relating
to obesity. The results indicated a desire for
trainings to enable physicians to become
advocates in their community to assist in
policy changes. Another need that is cur-
rently being addressed is a community re-
source directory to provide information on
efforts to prevent and treat obesity. With 211
San Diego taking the lead, in collaboration
with Rady Childrens Hospital and the COI
as content experts, this directory is current-
ly being developed. The healthcare systems
and provider domain would welcome any
physician interested in participating on this
domain work group. If interested, please
contact Cheri Fidler at cfidler@rchsd.org
or at (858) 966-7748.
Another local initiative, the Healthy Eat-
ing, Active Community (HEAC), which is
based in Chula Vista and receives funding
from the California Endowment, offers a
unique project developed through the Cali-
fornia Medical Associations Obesity Pre-
vention Project. This project was piloted
with the HEAC by lead physician Chris
A p r i l 2 0 0 9
Searles, MD. After the successful pilot,
it has been extended to the COI govern-
ment domain and works in partnership
with County Parks and Recreation. The
RecreationRx program empowers Physi-
cian Champions to advocate for health
and obesity prevention in their area. The
concept is to promote health through rec-
reation by facilitating partnerships between
healthcare and recreation providers and the
communities they serve. The program pro-
motes the benefits of physical and mental
health as essential in any plan to change
ones lifestyle. The Recreation Prescrip-
tion is an actual prescription for physical
activity. It supports physicians recommen-
dations for healthy activity and social con-
nections and builds community partner-
ships. To receive prescription pads, learn
how to implement your own program, and
receive updates and step-by-step guidance,
visit RecreationRx.org.
Grasping the concept of the social de-
terminants of health and understanding
how this principle links to health equity
is vital to improving the health of patients,
communities, and the nation. Overall, the
health of San Diego County residents is
improving in many key health outcomes,
such as heart disease, stroke, infant mor-
tality, asthma, and cancer. However, when
we explore the prevalence and rates of
these conditions by race and ethnicity, in
some cases the numbers reveal differences
among some groups. Our goal is to achieve
health that is better than the best for all
residents of San Diego County. Partnership
with community stakeholders will be the
key to this success. As physicians you are
part of this solution.
Note: To read this article with references, visit
SDCMS.org.
A b o u t t h e A u t ho r : Dr. Woo-
ten, SDCMS and CMA member since
2006, is the public health officer for the
County of San Diego, Health and Human
Services Agency. She is board certified in
family medicine and has a masters de-
gree in public health. From 1990 to 2001,
she practiced medicine as a faculty mem-
ber in the UCSD Department of Family
and Preventive Medicine; she joined the
County of San Diego in March 2001. Dr.
Wooten remains a UCSD volunteer asso-
ciate clinical professor and is an adjunct
professor at SDSUs Graduate School of
Public Health.
| S A N D I E G O P H Y S I C I A N . o r g 25
 Technology Matters
By Ofer Shimrat

Cloud
Computing
and
Healthcare
Bad Weather or Sunny Forecast?

26 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
What Is Cloud Computing? with the inner workings of the remote one form or another of Cloud Computing
In current IT circles, the Internet is often application and only see and use the it is everywhere.
referred to as The Cloud. Think services
AKT_SDP_08:Layout
of mul- 1 being requested,
8/22/08 3:52without
PM Pagecontrol
1 Whether you are banking online with
tiple computers in a giant mesh all inter- of the technology infrastructure to make your computer, viewing GPS-aware res-
working together. Now think of many such it happen. taurant reviews on your mobile device, or
meshes and step back see The Cloud? Keep that in mind when we traverse sending live digital media through your
Although you may not physically see healthcare. webcam, you are using services in The
it, The Cloud is there for all sorts of sig- Cloud, i.e., not installed or contained with-
nals: data, telephony, digital, etc. The term Who Uses Cloud Computing? in your local device.
Cloud Computing denotes the use of Almost everyone in this day and age with A case can be made that anytime you
cloud- or Internet-based computers for a an electronic communications device uses used dial-up in the early days of the Inter-
variety of services. In its historically short
life span, its usage is still evolving as we
speak.

As definitions
evolved and got
refined, Cloud
Computing now
implies the user
experience moving
away from
personal computers
and into a cloud
of computers.
The expression The Cloud has its
roots in telephony applications in the early
1990s. Telephone utilities were leveraging
The Cloud for their switching and routing
in order to deliver the proper connections
for phone calls, faxes, live feeds, signals,
etc.
Personal:
The Internet, in its infancy right around Income Tax Planning
that same time, leveraged those connec- Wealth Management
tions to allow users to dial up and reach Financial Planning
their intended Internet forum or tech
support area. We now fondly look back at
those times and wonder how business was Local:
conducted at dial-up speeds. Employee Benefit Plans Ron Mitchell, CPA
By the turn of the millennium, the In- Profitability Reviews Director of Health Services
ternet was moving at much faster speeds Outsourced professional services rmitchell@aktcpa.com
referred to as broadband and all the (CFO, Controller) 760-431-8440
computing equipment to make that hap-
pen was up there somewhere, and the
term in the cloud became all the rage. Global:
Then, around the middle of the decade, Organizational Structure
Cloud Computing was firmly in the lexi- Succession Planning
con as a way to define what the user was Internal Control Review and
doing: accessing computing services in the
cloud.
Risk Assessment
As definitions evolved and got refined,
Cloud Computing now implies the user
experience moving away from personal 5946 Priestly Drive, Ste. 200
computers and into a cloud of comput- Carlsbad, CA 92008
CPAs and Consultants
ers. Users of The Cloud are not concerned

A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 27
 net, you were leveraging The Cloud, but
were you?
Your computer was local, your software
application was local, your data was lo-
cal, and you were viewing it on your CRT
monitor locally. Back then, all you were us-
ing the Internet for was to transmit and re-
ceive data that, once the transmission was
complete, ended up locally.
In the early part of the decade, compa-
nies like Amazon began architecting their
websites in such a way that you could uti-
lize their services simply through the use
of a browser like Netscape or Internet Ex-
plorer.
Soon after, other companies got into the
fray, and, through the use of more robust
technologies, in the cloud applications
became more and more commonplace. By
the middle of the decade, most major cor-
porations with a large Web presence had
working and mature renditions of their
services completely in the cloud.
Fast forward to now when companies
like Google and Microsoft offer in the
cloud services that require hardly any ad-
ditional software on your local computer,
beyond the operating system of the com-
puter or device and a browser. Some ser-
vices are offered for free by merely signing
up, while others are offered as a recurring,
monthly, per-seat subscription; schemes
include Software as a Service (SaaS) and
Application Service Providers (ASP).
It is a trend and a pattern that is quickly
gathering steam.
28 S A N D I E G O P H Y S I C I A N . o r g
What Is Cloud Computing
As It Applies to Healthcare?
The trend appears to be irreversible. Many
software applications, services, and data
once in the realm of a local computer or
local server safely secure in your building
are now in the domain of the public Inter-
net. Private health information once con-
fined to these local networks is migrating,
wholesale, onto the Internet.
Patients voluntarily grant access to their
health records every time they sign a waiv-
er to the health insurer that then decides
on the payment disposition to the doctor,
pharmacy, or hospital. For the most part,
the collection and organization of this data
is completely legal.
It then follows that companies want to
automate and accelerate access to these re-
cords in order to offer in the cloud prod-
ucts and services to patients, doctors, and
institutions.
The fact that Google and Microsoft are
heavily invested in the cloud extends to
their new offerings for medical record ser-
vices, such as Microsofts HealthVault and
Google Health. While still in beta testing,
these software giants have partnered with
large healthcare providers for their pro-
grams: Microsoft with Kaiser Permanente
and Google with The Cleveland Clinic.
Microsoft and Google are two promi-
nent examples of many other company
offerings that are following the accelerat-
ing trend of placing previously local and
private health records in the cloud. This
| A p r i l 2 0 0 9
coming explosion of information will be
stored in massive data centers around the
world and will provide access to healthcare
records for patients, insurers, doctors,
pharmacies, and institutions.
Interesting timing and fascinating
convergence of events if you consider the
new Obama administration initiatives like
Transforming Healthcare Through IT
and Enabling Healthcare Reform Using
Information Technology recommen-
dations by the Healthcare Information and
Management Systems Society (HIMSS) to
the Obama administration and the 111th
Congress.
How Will Cloud Computing
Affect Your Practice?
In the coming months and years, sev-
eral factors are converging into a perfect
storm of opportunity and challenges.
For most solo, small-, and medium-size
practices, Cloud Computing represents a
juncture of significance. Do you invest up
front and build your local computing in-
The fact that Google
and Microsoft are
heavily invested
in the cloud
extends to their new
offerings for medical
records services,
such as Microsofts
HealthVault and
Google Health.
frastructure and keep your data local or do
you amortize your investment over recur-
ring monthly charges and keep everything
in the cloud, including your data?
Either choice presents additional chal-
lenges: What about backups, disaster re-
covery and 99.999 percent uptime to the
Internet? What about HIPAA compliance
of these services and applications offered
both as local and in the cloud? What
about hybrid applications that leverage
both local infrastructure and The Cloud?
Carefully analyzing the options and act-
ing prudently could mean the difference
between bad weather and sunny forecasts
when it comes to implementation time.
By utilizing the SWOT analysis approach
strengths, weaknesses, opportunities,
and threats each practice could analyze
the adoption of a unique computing infra-
structure commensurate with their needs.
The convergence of the technologies as-
sociated with Cloud Computing and the
pronouncements laid out by the newly
passed American Recovery and Reinvest-
ment Act of 2009 (ARRA) will propel
practices of all sizes to carefully consider
their approach to their selection of the right
electronic medical record application.
According to the Certification Commis-
sion for Healthcare Information Technol-
ogy (CCHIT), more than 300 vendors
currently offer some variance of electronic
medical records some in the cloud,
some locally, and some in both. They in-
clude:
Electronic Health Records (EHRs)
Electronic Medical Records (EMRs)
Personal Health Records (PHRs)
Payer-based Health Records (PBHRs)
Electronic Prescribing (E-prescribing)
Financial/Billing/Administrative System
Computerized Practitioner Order En-
try (CPOE) Systems

The Bottom Line

As part of your SWOT analysis, determine
first which path your practice will take:
local, in the cloud, or a hybrid of both.
Then and only then procure your IT infra-
structure to meet the software, hardware,
and network requisites for that applica-
tion, in that order.
Correctly implementing and utilizing
information technology will offer your
practice enormous benefits local, cloud
computing, or a hybrid of the two. Your
practice will have better access to health-
care services and information that would
subsequently result in improved outcomes,
fewer errors, and increased cost savings
a sunny forecast to be sure.

About the A u t ho r : Mr.

Shimrat is founder and CEO of SDCMS-

25%
endorsed Soundoff Computing Corpo- SDCMS member physicians receive
ration, a consultancy specializing in IT PUbLICATIO
N OF THE
SAN DIEGO
COUNTY
mEDICAL
SOCIETY
mARCH
2009

OFFICIAL

products and services. Originally an ap-

plications developer, he brings database
methodology approaches to network im-
plementations. He combines practical ex- teeriSM
off
n VOlun
PhySiCia
perience as a thrice business owner with
best practices in providing organizations advertising in San Diego Physician.
with needs analysis, business logistics, U NITED
FOR A
H E A LT
HY SA
N DIEG
O

ICIANS

IT infrastructure, and proactive mainte-

PHYS

SeMinar
e Online
nOw P.9 P.16
S Viewabl e SCreening tOO
l
Contact Dari Pebdani at 858-231-1231
nance. Visit SoundoffComputing.com or
> SDCMS enC
FaMily ViOl are P.18
nting a healthC

or DPebdani@sdcms.org
> iMPleMe > ChineSe

call (858) 569-0300.

A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 29
Health Information
Technology
Electronic Health
Record Buyers
Beware
I
n a recent open letter to President
Obama, David Kibbe, a senior adviser
to the American Academy of Family
Physicians and expert on health informa-
tion technology (HIT), described the cur-
rent electronic health records (EHRs) as
costly, difficult to use, and unable to allow
hospitals, physician offices, or pharmacies
to easily share information about patients
medical histories and treatments. He wrote,
If Americas physician practices suddenly
rushed to install the systems of their choice,
it would only dramatically intensify the
[tower of] Babel that already exists.
The following points should help phy-
sician buyers understand why physicians
should approach EHRs and e-precribing
tools with extreme caution:
Affordability. Most stand-alone EHRs
cost a minimum of $10,000 per phy-
sician for purchase, installation, and
staff training. Maintenance and up-
grades can easily run up to $2,000 per
year per physician. Subscriptions for
EHRs typically cost $400 per month
By Stephen H. Carson, MD per physician.
30 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
Return on Investment: Although the
government and health plans reap
90 percent of the financial benefit of
EHRs, physicians are expected to pay
for the efforts in time and money. For
example, the current incentive dollars
for e-prescribing and pay-for-perfor-
mance may not amount to more than
$3,500 per physician per year hard-
ly enough to offset the costs, let alone
the headaches. Many of the incentives
are not guaranteed for more than four
years.
Reduction in Productivity: The average
primary care physician will experience
a 20 percent reduction in productivity
and collections in the first year of us-
ing a full-blown EHR. Beyond the first
year, productivity rarely surpasses what
it was with paper records for PCPs.
Interoperability: Physicians who buy
an independent e-prescribing tool or
EHR that is not fully integrated with
their practice management system for
demographic data, billing, and collec-
tions will be frustrated with the ongo-
 ing costs and headaches of making the
two systems work seamlessly. Anytime
there are upgrades to one system, there
are unanticipated costs and glitches
with the second system. There are also
major interoperability issues between
physicians and their hospitals, labs,
and radiology vendors. This connectiv-
ity is necessary to eliminate the errors
and the time associated with having to
re-key patient data into your EHR.
Unexpected Downtime: Solo and
small practices cannot afford dedicated
technicians to solve problems inher-
ent with electrical outages, computer
glitches, and server crashes.
Changing Requirements: EHRs will
need to incorporate ever-changing re-
quirements for clinical decision sup-
port, order entry, data capture and
information exchange between stake-
holders. Physicians will be regularly
forced to spend additional dollars to
modify their information systems.
Based upon the current incentive time-
tables, it is my recommendation that phy-
sicians should NOT start shopping for
hardware or software until the fall of 2010,
with the goal of launching in January 2011.
Although some physicians may want to
proceed sooner, my rationale for waiting is
as follows:
Cost of both hardware and software
will continue to drop over the next two
years.
Functionality of fully integrated prac-
tice management and EHR systems is
dramatically improving from month to
month. EHRs of the next decade will
need to include modules for popula-
tion health improvement, clinical de-
cision support, eligibility verification,
charge capture, claims adjudication,
HEDIS reporting, and interoperabil-
ity. Although there are some excellent
products on the market today, none of
the products is ready to meet the re-
quirements that are expected to be in
place within two years.
Microsoft Windows 7 is likely to re-
place Windows Vista in early 2010.
Open source platforms are likely to
heat up the competition among ven-
dors and drive the price of EHRs
downward. New adaptations of Vista
for the ambulatory physician will stim-
ulate disruptive innovation.
Inexpensive and energy-efficient, thin
client hardware will become an attrac-
tive option for physician offices.
Incentives for innovative programs run
by state, federal, regional, health plan,
and independent practice associations
will continue to evolve.
Standardized patient ID cards and
card readers that interface with prac-
tice management systems is a priority
for the Medical Group Management
Association (MGMA). MGMA esti-
mates that machine-readable patient
ID cards could save physician offices,
health plans, and hospitals as much
as $1 billion a year by eliminating un-
necessary administrative efforts and
denied claims.
Real-time claims adjudication through
the EHR will allow physician offices
to determine eligibility, deductible
thresholds, and CPT codes for imme-
diate adjudication and reimbursement
of the office visit. This feature is where
the real, long-term financial reward is
for physicians.
Standards: Under the stimulus act,
the Office of the National Coordinator
(ONC) for Health Information Tech-
nology will require EHRs to adopt new
sets of standards, specifications, and
certification criteria by December 31,
2009. These new standards will re-
A p r i l 2 0 0 9
sult in unanticipated upgrade costs for
those who have already purchased an
EHR.
ICD-10 code sets are likely to be re-
quired by October 2013 and require
tighter integration between clinical
and billing functions.
FDA Barriers: The FDA still prohib-
its the use of e-prescribing modules
to submit prescriptions for controlled
substances. This explains why fewer
than 5 percent of all prescriptions in
the United States have been filed elec-
tronically over the last year.
What about the HITECH Act in the
American Economic Recovery and Rein-
vestment Act? It is estimated that $17.2 bil-
lion of the $20 billion dollars set aside to
stimulate IT adoption will be in the form
of incentive programs under Medicare and
Medicaid. As currently written, ambula-
tory physicians participating in Medicare
will be eligible if they can demonstrate
If Americas physician
practices suddenly
rushed to install the
systems of their choice, it
would only dramatically
intensify the [tower of]
Babel that already exists.
that they are meaningful users of certi-
fied EHR technology (standards are to be
established before December 31, 2009).
Meaningful use is defined as being con-
nected in a way that improves the qual-
ity using measures selected by the ONC.
Incentives will be limited to 75 percent of
Medicare-allowed charges in any year and
up to $44,000 over five years. Physicians
| S A N D I E G O P H Y S I C I A N . o r g 31
Health Information
Technology
practicing in health professional shortage
areas can receive an additional 10 percent.
Physicians who start after 2014 will not re-
ceive any incentives.
For Medicare-covered services rendered
during 2015 or after by a professional who
cannot demonstrate meaningful EHR use,
the Medicare physician fee schedule will
be reduced by 1 percent for 2015, 2 percent
for 2016, and 3 percent for 2017. There
is an escape clause for professionals who
can demonstrate significant hardship, but
that clause will apply to a professional for a
maximum of five years.
Do not buy separate
practice management and
EHR systems in the hope
that they will always work
well together.
Unfortunately, the money from the
Medicare and Medicaid programs will be
paid out over four or five years and wont
be available until 2010 or 2011. The Act
provides for comparable incentives and
disincentives for professionals providing
substantial services through Medicare Ad-
vantage plans.
The Act also provides for payments to
those states that have approved Medic-
aid plans and programs to encourage the
adoption and use of certified EHR technol-
ogy. Specifically, these states will receive
100 percent of the payment outlays of their
programs and 90 percent of their costs of
administering such programs. Payments
to physicians cannot exceed 85 percent of
average allowable costs for certified EHR
technology and are capped at $25,000 for
the first year and $10,000 for subsequent
years. These amounts will be reduced by
two-thirds of that amount for pediatri-
cians. Eligible providers must have at least
32 S A N D I E G O P H Y S I C I A N . o r g
a 30 percent Medicaid patient load, and pe-
diatricians must have at least a 20 percent
Medicaid patient load. Federally qualified
health centers or rural health clinics must
see at least a 30 percent load of patients
classified as needy, which is broader
than Medicaid beneficiaries.
For those of you who are ready to make
the leap despite the challenges, I would of-
fer the following advice:
Purchase a fully integrated practice
management system and EHR. Do not
buy separate systems in the hope that
they will always work well together.
Make sure the integrated system sup-
ports the full set of HIPAA transaction
standards, appointment scheduling,
patient reminders, electronic eligibility
verification, advanced claims editing
(including health savings accounts),
automated payment posting with elec-
tronic remittance advice, integrated
credit card processing, configurable
reporting, the ICD-10 code sets, and, if
necessary, specialized Medi-Cal claims
processing that addresses medical
home requirements. In addition, do
not forget to research the ability of the
system to interface with health plans
and clearinghouses.
Do not waste your time on stand-alone
e-prescribing you are only going to
have to dump it later for an EHR. Re-
member, the incentives from Medicare
for e-prescribing drop to 1 percent in
2012, to 0.5 percent in 2013, and then
they disappear.
Pick an EHR suited to your specialty.
Get advice from your colleagues and
your specialty society. For example,
voice recognition in the EHR is often a
big plus for surgeons and enables sav-
ings on transcription costs. Look for
software that automatically flags com-
mon tasks that are unique for your
specialty (e.g., cancer screenings for
| A p r i l 2 0 0 9
internists and family practitioners).
2
Vendor Reputation: Pay attention to
the vendors track record for service
and support.
Interoperability: If possible, find an
EHR that can receive data from your
preferred lab and hospital and deliver
patient-specific data into the correct
field in each of your patients electron-
ic charts.
Application service providers using a
subscription model for maintaining
and servicing your office is the best
approach for physicians in small- and
medium-size practices.
Workflow Planning, Staff Training,
and Implementation: An experienced
vendor will work with physicians and
their staffs to map out the ideal work-
flow for the office and develop a care-
fully planned out schedule for train-
ing and implementation. Physicians
should not underestimate the time or
importance of these efforts.
Check the 2008 Best in KLAS Awards
based on customer satisfaction with
healthcare information technology
vendors and consultants.
A b o u t t h e A u t ho r : Dr. Car-
son, SDCMS and CMA member since
1983, has for the past 25 years served as
a consultant for health systems, schools
of medicine, health plans, hospitals, and
medical groups. In 1992, Dr. Carson
founded Primary Care Associates (PCA),
an independent practice association of 80
primary care physicians and more than
300 specialists serving the north coastal
region of San Diego County. Dr. Carson
served as the chief medical officer for the
San Diego County Medical Society Foun-
dation from 2005 through 2008. He con-
tinues to practice pediatrics and pediatric
pulmonary medicine in Hillcrest.

E-prescribing
Resources
Available to Members at SDCMS.org
By Lauren Wendler
E
-prescribing is the electronic
generation, transmission,
and filling of a prescription.
It strives to reduce the number of
medication errors and adverse drug
effects, and improve standards in
patient safety. Surescripts-RxHub
is a network that securely links e-
prescribing systems to the major
health plans, pharmacy benefit
managers, and pharmacies.
Prescribers have the choice of
using a standalone solution or a
system integrated with an EMR
(electronic medical record). For
2009, the e-prescribing Medicare
incentive will provide 2 percent of
the total estimated allowed charges
for professional services covered
by Medicare Part B as provided by
an eligible prescriber during one
calendar year. Certain CPT codes
must be used for at least 10 percent
of the total Medicare Part B-allowed
charges to be eligible. The list of
codes can be found in Medicares
Guide to E-prescribing (available
at SDCMS.org).
Before a physician makes the
adoption decision, evaluating the
current state of the practice is im-
portant in order to prevent future
adoption failures. It is hard to put
a finger on which vendor has the
best e-prescribing product for your
practice. Located on SDCMS web-
The STaTe of your I.T.
Computers, Tablets, Servers, Network, Wireless
Needs Analysis, Planning, Infrastructure & Logistics
Network Design, Hardware, Software & Installation
Backup, Security & Disaster Recovery
Computer Training & Proactive Maintenance
FREE site inspection
for SDCMS members
www.soundoffcomputing.com
Ofer Shimrat (858) 569-0300 x 202
Partners with:
Integrated Communications & Data
Electronic Medical Records
TCS_SDP_08:Layout 1 8/15/08 10:16 AM Page 1
site are tools to help physicians
research e-prescribing vendors, us- Endorsed by:
ing a vendor-neutral approach. The
resources available to members at
SDCMS.org to help educate them
and their staffs in e-prescribing in-
clude:
SDCMS E-prescribing webinar
E-prescribing for Dummies
(filmed February 24, 2009)
along with a PowerPoint presen-
tation.
AMAs Clinicians Guide to E-
prescribing.
Medicares Guide to E-prescrib-
ing.
Illumisys PowerPoint presenta-
tion: The Benefits of E-prescrib-
ing.
National E-prescribing Patient
Safety Initiative webinar: E-pre-
scribing: Facts and Myths (filmed
October 9, 2008).
Please contact me, Lauren Wen-
dler, your office manager advocate,
at SDCMS at (858) 300-2782 or at
LWendler@SDCMS.org should
you have any questions.
About the A u t ho r :
Ms. Wendler is your office man-
agers SDCMS office manager
advocate and can be reached at
(858) 300-2782 or at LWendler@
SDCMS.org.
A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 33
Health Information
Technology
The American
Recovery and
Reinvestment Act
of 2009 (HR1)
Explanation of Health
T
he American Recovery and Re-
investment Act of 2009 (ARRA)
Information Technology provides substantial financial
Provisions (1) incentives ($19 billion over a specified
five-year period) that will help physicians
purchase and implement HIT systems.
Beyond adequate financing, a key element
to the widespread adoption and use of HIT
is the development of uniform electronic
standards that allow various HIT systems
to communicate with each other. ARRA
requires the Department of Health and
Human Services (HHS) to develop such
standards by December 31, 2009. Begin-
ning in 2011, Medicare physicians who
implement and report meaningful use of
electronic health records (EHR) will be
eligible for an initial incentive payment up
to $18,000. While ARRA includes a provi-
sion that will reduce Medicare payments
(starting at 1 percent) for physicians who
do not use EHR systems, this does not take
effect until 2015, and there are exceptions
for significant hardship cases. As noted
By the american below, some of the details on the imple-
medical association mentation of ARRAs HIT-incentive provi-
34 S A N D I E G O P H Y S I C I A N . o r g | A p r i l 2 0 0 9
sions will be worked out through the regu-
latory rulemaking process in the coming
months. AMA will be closely monitoring
and providing input to ensure that the HIT
provisions are implemented in a manner
consistent with the intent of ARRA.
HIT Incentive and
Penalty Program
ARRA provides financial incentives
through the Medicare Part B program to
encourage physicians to adopt and use
qualifying EHRs in a meaningful way.
Meaningful use of EHRs will be defined
by HHS during the rulemaking process
and may include reporting requirements
on quality measures. ARRA also autho-
rizes HHS to provide competitive grants to
states to make loans available to healthcare
providers to assist them with HIT acquisi-
tion and implementation costs.
Physicians (non-hospital based) are
eligible for Medicare incentive payments
based on an amount equal to 75 percent
of the allowed Medicare Part B charges
up to a maximum of $18,000 for early
adopters whose first payment year is 2011
or 2012. The secretary of HHS will define
the reporting period(s) with respect to a
payment year. Incentive payments would
be reduced in subsequent payment years,
eventually phasing out in 2016. Physicians
who do not adopt/use an EHR system
before 2015 will face a reduction in their
Medicare fee schedule of 1 percent in 2015,
2 percent in 2016, and 3 percent in 2017
and beyond. The secretary of HHS has the
authority to make exceptions to this reduc-
tion on a case-by-case basis for physicians
who demonstrate significant hardship (e.g.,
a physician who practices in rural areas
without sufficient Internet access).
The following table shows how the incen-
tives and potential reductions are expected
to work from 2010-2017 (2, 3):
First Payment Year Amount
First and Subsequent Payment
Payment Year Amounts in Following Years
$63,750, over a six-year period.
In the event that the secretary of HHS
finds that the proportion of healthcare pro-
viders who are meaningful users of EHRs is
less than 75 percent, the secretary is autho-
rized to increase penalties beginning in 2018,
but penalties cannot exceed -5 percent.
ARRA Will Establish HIT
Policy and Electronic Standards
ARRA formally establishes the role and
functions of the Office of the National Coor-
dinator for Health Information Technology
(ONCHIT) within HHS, which is to pro-
mote the development of a nationwide in-
teroperable HIT infrastructure. (ONCHIT
was already created by Executive Order in
2004.)
ARRA establishes the HIT Policy and
Reduction in Fee
Schedule for Non-adoption / Use
able a qualifying EHR system to healthcare
providers for a nominal fee. AMA will be
seeking clarification from HHS on the cost
of such a system and the date it will be avail-
able. Physicians do not need to purchase
the governments EHR system; they can
purchase any qualifying system (i.e., meets
certain standards, including interoperabil-
ity) from a vendor of their choice.
AMA policy strongly supports positive fi-
nancial incentives for physicians to acquire
and implement HIT. Throughout the legis-
lative process, AMA urged flexibility in the
timeline for HIT adoption and use, given
the uncertainties surrounding the readi-
ness of standards, the availability of EHR
systems that are interoperable, secure, and
affordable, and the rule-making process.
AMA will continue with efforts to ensure
that physicians obtain the funds and assis-
tance they need to transition their practices
from paper to electronic-based systems.

2011 $18k, $12k, $8k, $4k, and $2k $0 Notes:

2012 $18k, $12k, $8k, $4k, and $2k $0 1) This summary will be updated when ad-
2013 $15k, $12k, $8k, and $4k $0 ditional details become available during
the rule-making process.
2014 $12k, $8k, and $4k $0
2) Physicians in rural health professional
2015 $0 -1 percent of Medicare fee schedule shortage areas who adopt/use EHRs are
2016 $0 -2 percent of Medicare fee schedule eligible to receive a 10 percent increase
on the incentive payment amounts de-
2017 $0 -3 percent of Medicare fee schedule
and thereafter scribed.
3) Physicians who report using an EHR
Incentives under the Medicaid program Standards committees, which comprise system that is also capable of e-prescrib-
are also available for physicians, hospitals, public and private stakeholders (e.g., physi- ing will no longer be eligible for the e-
federally qualified health centers, rural health cians) to provide recommendations on the prescribing bonuses established by the
clinics, and other providers; however, physi- HIT policy framework, standards, imple- Medicare Improvements for Patients
cians cannot take advantage of the incentive mentation specifications, and certification and Providers Act (MIPPA); they will be
payment programs under both the Medicare criteria for EHRs. eligible for HIT incentives only to avoid
and Medicaid programs. Eligible pediatri- HHS is required to adopt, through the double-dipping. Also, e-prescribing
cians (non-hospital based), with at least 20 regulatory rule-making process, an initial penalties sunset after 2014, so that no
percent Medicaid patient volume, could re- set of standards, implementation specifica- physician will be subject to penalties for
ceive up to $42,500, and other physicians tions, and certification criteria by December failing to both e-prescribe and use an
(non-hospital based), with at least 30 percent 31, 2009, for qualifying EHRs. EHR.
Medicaid patient volume, could receive up to ONCHIT is authorized to make avail-

A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 35
Health Information
Technology
HIT Stimulus Could
Bring $3 Billion in New
Funds to California
CHCF Issue Brief Analyzes Opportunities and
Recommends State Action
T
he federal stimulus bill signed by
President Barack Obama in Feb-
ruary offers unprecedented oppor-
tunities to increase health information
technology (HIT) adoption among Cali-
fornia providers and facilitate the secure
exchange of patient health information,
according to a February 23, 2009, issue
brief published by the California Health-
Care Foundation (CHCF).
The Health Information Technol-
ogy for Economic and Clinical Health Act
(HITECH), a component of the American
Recovery and Reinvestment Act (ARRA) of
2009, provides roughly $36 billion in out-
lays for health information exchange infra-
structure and incentive payments to phy-
sician practices adopting electronic health
records (EHRs), chronic disease manage-
ment systems, and other technologies. In
California, the stimulus funding could add
up to more than $3 billion, according to
the issue brief.
CHCFs issue brief outlines necessary
steps to take advantage of these provisions
and makes specific recommendations to
Governor Schwarzenegger and the Cali-
By The California HealthCare Foundation
36 S A N D I E G O P H Y S I C I A N . o r g
fornia Legislature to ensure that Califor-
nia successfully competes for and makes
effective use of HITECH funds. The key
recommendations include:
Appoint a Deputy Secretary of Health
Information Technology, within the
Health and Human Services Agency,
to coordinate and drive health IT and
health information exchange planning
and implementation.
Appoint a nonprofit state-designated
entity to apply for HIE implementa-
tion funding on behalf of the state.
Establish policies, procedures, and
information systems required to sup-
port Medi-Cal incentive payments for
adoption of EHRs by physicians, hos-
pitals, community health centers, and
others.
Actively engage with federal officials
and policymakers to ensure Califor-
nia has a meaningful voice at the table
during the regulatory process that will
determine the HITECH Acts specific
funding mechanisms.
Appropriate funds in the amount re-
quired to match the federal funding
| A p r i l 2 0 0 9
authorized under the HITECH Act
in order for California to take full ad-
vantage of the opportunities available
through the Act.
T
 ake steps to educate patients, con-
sumers, and the public on existing
health privacy safeguards and new
protections intended to ensure the
confidentiality and security of personal
health information.
For the past 10 years, CHCF has worked
to accelerate the adoption and effective use
of new information technologies in health-
care, pushing for national data standards,
interoperable systems, development of
patient privacy protections, and promot-
ing use of patient-centered and patient-
In California,
the stimulus funding
could add up to more
than $3 billion.
controlled tools for self-management of
chronic conditions. To access An Un-
precedented Opportunity: Using Federal
Stimulus Funds to Advance Health IT in
California, visit CHCF.org.
A b o u t t h e A u t ho r : The Cali-
fornia HealthCare Foundation (CHCF) is
an independent philanthropy committed
to improving the way healthcare is deliv-
ered and financed in California. By pro-
moting innovations in care and broader
access to information, CHCFs goal is to
ensure that all Californians can get the
care they need, when they need it, at a
price they can afford.
 Time Well Spent?
Other CHCF Publications
Accessible at CHCF.org
Electronic Health Records:
Physician Practices: Are Application Service Providers Right
for You? First Consulting Group (October 2006) at www.
chcf.org/topics/view.cfm?itemID=125716
Electronic Health Records Versus Chronic Disease Management Choose Allscripts Enterprise
Systems: A Quick Comparison (March 2008) at www.chcf. EHR Powered by CHMB
org/topics/chronicdisease/index.cfm?itemID=133586 Solutions
Open-source EHR Systems for Ambulatory Care: A Market
Assessment (January 2008) at www.chcf.org/topics/view.
CHMB Solutions The industry leader in electronic
cfm?itemID=133551 Delivers Business, medical records technology
Creating EHR Networks in the Safety Net (April 2008) at Clinical & Technology Award-winning software to fit
www.chcf.org/topics/view.cfm?itemID=133595 Solutions to your practice
Physician Practices Ability to customize to any level
or specialty
Electronic Prescribing: Serving over
600 physicians Cost-effective ASP platform
Getting Connected: The Outlook for Electronic Prescribing in
California (November 2008) at www.chcf.org/topics/view. IT Services & Maintenance
cfm?itemID=133793 Tier 3-level secured
The Prescription Infrastructure: Are We Ready for E-prescrib- hosted servers
ing? (January 2006) at www.chcf.org/topics/chronicdis- Billing & Revenue
ease/index.cfm?itemID=118337 Cycle Management

Personal Health Records/Consumers: Project4:Layout 1 9/22/08

www.chmbsolutions.com 11:22 AM Page 1
The Wisdom of Patients: Healthcare Meets Online Social Me- 800.727.5662
dia (April 2008) at www.chcf.org/topics/chronicdisease/
index.cfm?itemID=133631
Perspectives on the Future of Personal Health Records (June
2007) at www.chcf.org/topics/chronicdisease/index.cfm? Tracy Zweig Associates
itemID=133289 A REGISTRY & PLACEMENT FIRM
Whose Data Is It Anyway? Expanding Consumer Control
over Personal Health Information (February 2008) at www.
chcf.org/topics/view.cfm?itemid=133577
Helping Patients Plug In: Lessons in the Adoption of Online Physicians
Consumer Tools (June 2008) at www.chcf.org/topics/view. Nurse Practitioners
cfm?itemID=133659
Physician Assistants
Telehealth:
Telemedicine in California: Progress, Challenges, and Oppor-
tunities (July 2008) at www.chcf.org/topics/chronicdis-
ease/index.cfm?itemID=133682
Delivering Care Anytime, Anywhere: Telehealth Alters the
Medical Ecosystem (November 2008) at www.chcf.org/top-
ics/view.cfm?itemID=133787

Other Related Resources:

Snapshot: The State of Health Information Technology in
California, 2008 (January 2008) at www.chcf.org/topics/
chronicdisease/index.cfm?itemID=133552 Locum Tenens
Gauging the Progress of the National Health Information
Technology Initiative: Perspectives From the Field (January Permanent Placement
2008) at www.chcf.org/topics/view.cfm?itemID=133553
Open Source Software: A Primer for Healthcare Leaders (March 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
2006) at www.chcf.org/topics/view.cfm?itemID=119091 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

t z we i g @ t r a c y z we i g . c o m
www. t r a c y z we i g . c o m

A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 37
Health Information
Technology
The Infobutton
Knowledge-based System Meets EHR
By Craig Haynes
T
he development and deployment
of the electronic health record
(EHR) provides opportunities for
improved information management on
both the back end (administration) and
the front end (user interface). On the back
end, the hope is that with interoperable
systems, healthcare organizations, doc-
tors, patients, and insurers will become
more efficient, more proficient, and safer.
Moreover, there is also the hope that costs,
if not reduced, will at the very least be con-
tained. On the front end, the hope is that
the EHR interface will make not only pa-
tient information more accurate, timely,
and accessible, but that it will also do the
same for knowledge-based information.
The Infobutton is a developing technol-
ogy created in order to provide contextual,
timely delivery of knowledge-based infor-
mation to caregivers from within the EHR
environment, i.e., at the point of care.
The Infobutton is an integrated ap-
plication within the EHR that, when ex-
ecuted, creates a query to a linked, pre-
selected medical reference. In addition,
the Infobutton is also designed to extract
38 S A N D I E G O P H Y S I C I A N . o r g
specific data tagged in the patient record,
such that an Infobutton embedded next to
the diagnosis of pulmonary hypertension
in the EHR of Jane Doe, age 45, will pro-
vide a medical reference relevant not only
to pulmonary hypertension, but, if tagged
(searchable), the entry will also match the
demographic data in the patients record,
as well as any other searchable attributes
tagged in the patients record. (See Illustra-
tion: The Infobutton appears as a dot next
to the items listed in the patient record un-
der the headings: chief complaints, ac-
tive diagnoses, etc.)
HL-7 (the ANSI standards develop-
ment organization) has developed a stan-
dard for the design and implementation
of Infobutton technology, and there have
been several early adopters among clini-
cal information system (CIS) vendors and
medical reference publishers.
There are many questions and issues
that arise when considering Infobutton
technology for a CIS. These questions vary
depending on the healthcare setting, the
CIS vendor, and the expertise available to
advise customers on such matters. The
leading CIS vendors (EPIC, Cerner,
| A p r i l 2 0 0 9
GE, McKesson, et al) have partnerships
with content publishers (e.g., Microme-
dex, Elsevier, et al) and some endeavor
to sell package deals to CIS buyers. Pub-
lishers supporting content integration will
work with existing CIS customers (i.e.,
those who already have a CIS contract) in
order to deploy the Infobutton technology
sometimes for an additional, annual li-
censing fee. Customers should determine
if their CIS has a partnership with the pub-
lisher in question and, if not, determine if
the two parties can work together to deploy
the technology.
At large healthcare organizations with
medical libraries and professional librar-
ians, it is highly advisable that the organi-
zations CIS implementation team work
directly with the library to determine exist-
ing electronic content licenses. Licensing
the same content twice is not a desirable
outcome. In smaller, private practices and
non-acute-care settings, working with us-
ers and the vendor to determine the knowl-
edge-based system needs of the practice/
setting is definitely worth the investment
of time. For example, if the practice al-
ready licenses Dynamed or UpToDate,
and the clinicians are happy with this con-
tent, they should work with the publisher
and the CIS vendor to determine if either
or both support the HL-7 Infobutton API
Standard, and then seek to deploy it.
On the CIS side, buyers should beware
of vendors including knowledge-based
systems or Infobutton links to content of
unknown origin. Stay with name-brand
clinical content providers, such as Elsevi-
er, Micromedex, Wolters-Kluwer, et
al. These publishers have the resources
to maintain and update their content on a
regular basis and to provide technical sup-
port and training. On the publisher side,
verify that the content provider supports
one or more of the industry standard con-
trolled vocabularies supported by the CIS
(e.g., ICD9-CM, MeSH, SNOWMED-
CT, et al) and that the publisher is com-
mitted to expanding its content tagging
and meta-data.
About the A u t ho r : Mr.
Haynes is head of the UCSD Medical Cen-
ter Library.
Corporate Legal Services
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39
 Classifieds
OFFICE SPACE
LA MESA OFFICE SPACE TO SHARE: Over
6,000ft2 OB/GYN office of four doctors with one
leaving, available immediately. Space is ideal for
a medical practice or clinical studies, and is lo-
cated on Grossmont Hospital campus. Contact
La Mesa OB/GYN at (619) 463-7775 or fax letter
of interest to (619) 463-4181. [648]
MEDICAL SPACE FOR LEASE: Mention you
saw this ad on SDCMS website for SIX months
free rent with a five-year lease! EL CAJON:
1,400ft2 with four exam rooms, large reception,
and nurses station; doctors office has private
bath with shower. EL CAJON: 2,962ft2 with six
exam rooms, lab room, three doctors offices,
large reception office, nurses station, loft with
lounge, large storage room, plus more. SANTEE:
1,800ft2 with six exam rooms, reception sepa-
rate from nurses station, doctors office, X-ray,
and dark room. Deal direct with owner and find
how accommodating we can be. Call during of-
fice hours: (619) 442-7200 or after hours (619)
517-1193. [696]
Leasing, Renewals & Sales:
Call the Healthcare Real Estate Special-
ists at Colliers International for a com-
plete inventory of all available medical
office space for lease or for sale in your
area, or for valuable vacancy and absorp-
tion information. Use our knowledge and
expertise to help you negotiate a new
lease, renewal, or purchase to assure you
obtain the best possible terms. There is
no charge for our consulting services.
Contact Chris Ross at 858.677.5329
email chris.ross@colliers.com
MEDICARE-CERTIFIED SURGERY CENTER:
Reasonable rates for use of Medicare-certified
surgery center. Call (619) 464-9876 and speak
to Mira. [694]
LA MESA OFFICE SPACE: Office space avail-
able in beautiful Victorian house in La Mesa. Call
(619) 464-9876 and speak to Mira. [693]
SPACE FOR LEASE: Beautiful office space
available for lease in a booming location lo-
cated just outside of downtown San Diego, with
ocean views, and a beautiful skyline. The space
available includes two exam rooms and a phy-
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exam room for overflow, a lobby, kitchen, chart
room, storage, front desk, and nurse station.
The practice is fully equipped and fully staffed.
Includes an EMR system, which means this is a
paperless office! The staff is very friendly, and
the office manager extremely experienced. New
doctor may choose to join the team or practice
solo. This is a family practice, but the team also
includes a PT chiropractor and podiatrist. Please
contact info@promed-financial.com or (888)
277-6633 for details. [692]
To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge
(excepting Services Offered ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.
40 S A N D I E G O P H Y S I C I A N . o r g
NEWLY REMODELED CORNER BUILDING IN
HILLCREST (1295 UNIVERSITY AVE, 2ND
FLOOR): Flexible space between 300 and
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overlooking University Avenue. Covered, se-
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the entrance, staircase, and elevators; ADA bath-
rooms and electric doors. Near major hospitals,
freeway 163, public transportation and Ralphs
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allowances possible with long-term lease. Lease
terms and rent negotiable. Available April 2009.
Please call (858) 212-4562 or email samimi9@
gmail.com for more information. [689]
OFFICE AVAILABLE ON SCRIPPS ENCINITAS
LOT: In desirable building on Scripps Encinitas
lot. Share elegant office that has just undergone
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doctors desk, your own exam room, front desk,
common waiting area, staff bathroom including
shower, and kitchen. Contact us at San Diego
Vein Institute at (760) 944-9263. [688]
MEDICAL OR PROFESSIONAL OFFICE SUITES
FOR LEASE, EL CENTRO, CA: In historic down-
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West State Street at http://info.svn.com/Dottie.
Surdi. Direct inquiries to (858) 349-2007 or dot-
tie.surdi@svn.com. [686]
NEW MEDICAL BUILDING ALONG
I-15: Pinnacle Medical Plaza is a new
80,000 SF building recently completed
off Scripps Poway Parkway. The location
is perfect for serving patients along the
I-15 from Mira Mesa to Rancho Bernardo
and reaches west with easy access to
Highway 56. Suites are available from
1,00011,000 SF and will be improved to
meet exact requirements. A generous im-
provement allowance is provided.
For information, contact Ed Muna at
619-702-5655, ed@lankfordsd.com
www.pinnaclemedicalplaza.com
MEDICAL OR PROFESSIONAL OFFICE
SUITES FOR LEASE, YUMA AZ: Directly
across from new Yuma Regional Medical Center.
Prime location; build to suit, and competitive
rates with tenant incentives. Ideal for sole prac-
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700ft2 within the clinic. Ample onsite parking,
public transportation nearby. Visit website at
2475 South Avenue A http://info.svn.com/Dot-
tie.Surdi. Direct inquiries to (858) 349-2007 or
dottie.surdi@svn.com. [685]
SUITES FOR LEASE, MISSION VALLEY PRO-
FESSIONAL MEDICAL/OFFICE BUILDING:
| A p r i l 2 0 0 9
Prime location, build to suit, and competitive
rates with tenant incentives make this a fabu-
lous value. Suites approximately 1,000ft2. At RT
15 and RT 8, just minutes from six major hos-
pitals. Ample parking. Easy freeway access and
public transportation nearby. Visit website for
Riverview Center, 3633 Camino del Rio South
at http://lease.svn.com/3633Camino. Direct in-
quiries to (858) 349-2007 or dottie.surdi@svn.
com. [684]
POWAY OFFICE SPACE TO SUBLET: Newly
remodeled, 3,000ft2 office space to sublet.
Ground level, high-end medical office building
with easy access from both the 56 and 15. Sepa-
rate administrative space with possible proce-
dure room available. Please contact (858) 668-
6502 or hsears@sdcpms.com. [683]
Class A Medical building
for sale or lease: 3-Story,
55,450/SF located at 838 Nordahl Road
in San Marcos, CA. Suites from 1,000/
SF. Premier location. Easy freeway ac-
cess & close proximity to restaurants
& Sprinter. Shower & locker facilities.
Resort quality restrooms. Tropical land-
scaping. Koi ponds. Panoramic views.
Latest in green building design stan-
dards with utility cost savings. Sched-
uled for completion in May 2009.
For more information contact
Mark Avilla (760) 431-4223
mavilla@breg.com
www.nordahlmedicalcentre.com
www.brecomercial.com
OFFICE SPACE TO SHARE: Low-volume fam-
ily medicine physician has space to share in his
1000ft2 office at 285 N. El Camino Real in En-
cinitas. Can reserve as little as one half-day per
week. Please call or email Marty at (760) 436-
7464 or at mschulman@ucsd.edu. [682]
HILLCREST MEDICAL OFFICE ACROSS FROM
SCRIPPS MERCY HOSPITAL: Office sublet
available in the Mercy Medical Building directly
across from Scripps Mercy Hospital. Great space
for an adult primary care or a specialist. First
floor, excellent staff, T1 line, EHR capable, voice-
mail, website, and more! Call for more informa-
tion and a tour: (619) 205-1480. [674]
OFFICE SPACE FOR LEASE: Hillcrest, Mercy
Medical Building (4060 Fourth Ave., 6th floor).
1947 usable square feet, consisting of four exam
rooms, one large OR-style procedure room, two
business offices, large waiting area, and small
lab area. Beautiful views of San Diego. Copious
shelves for medical files. Reception counter. T1
capability, and 220 volt outlet. Please call (858)
361-7300 or the onsite building manager at
(619) 293-3081. Available by the end of January
2009. [671]
 SDCMS
Foundation
Project Access San Diego
Project Access San Diego is a NEW and
INNOVATIVE project designed to coordinate
healthcare volunteerism here in San Diego
County. Together we can ensure that our
vulnerable populations have access to needed
healthcare services.
Sign up NOW at SDCMSF.org
We need your volunteer commitment to help even one patient.
A p r i l
Your commitment to Project Ac-
cess is required for our success. We
want to make it easy for you to par-
ticipate, so Project Access provides
the following case-management
services to enrolled patients:
Enrolling Patients Based on
Need: We verify financial status
so that you can be assured that
your volunteer service is reaching
those who are most in need.
Making Appropriate Referrals:
We use referral guidelines that
ensure that when a Project Ac-
cess patient comes to your office,
he or she can take full advantage
of the visit.
Providing Enabling Services:
We provide services such as
transportation and translation
so that you dont have to wonder
if a patient is going to miss an
appointment or if there will be a
language barrier.
Providing Case Management
Services: We work with each
patient one-on-one to coordinate
follow-through on all medical
needs.
Providing All Needed Services:
Through our partnerships, we en-
sure that a full scope of services
is available to all of our patients,
from office visits, hospital ser-
vices, and even a defined phar-
macy benefit.
Project Access is actively recruiting
physicians, hospitals, and ancillary
service providers to participate in
the program.
Please make a
commitment today.
Visit our website at
SDCMSF.org to learn
more and sign up.
2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 41
 Classifieds
OFFICE SPACE TO SHARE: Currently occupied
by orthopedic surgeon situated in La Mesa. Five
minutes away from Alvarado Hospital and 10
minutes from Grossmont Hospital. Looking to
share with part-time or full-time physician. Fully
furnished, fully equipped, with X-ray equipment
and three exam rooms. Please call (619) 668-
0900 or email either rcham1000@aol.com or
carmen@drcham.com. [666]
LA JOLLA OFFICE SPACE AVAILABLE AT
XIMED MEDICAL BUILDING: Brand new, reno-
vated office space available, preferably to a pri-
mary care MD to share. This is a rare opportu-
nity to have a presence at the prestigious XiMed
Medical Building right next to Scripps Memorial
Hospital and to reduce your overhead by shar-
ing space. Currently, the office is being used by a
single physician part of the time. Flexible to any
arrangement proposed. Call (858) 837-1540 or
email melkurtulus@hotmail.com. [664]
MEDICAL OFFICE SPACE FOR LEASE IN EN-
CINITAS: Available August 2009. Share space
with established physician-owner. Office located
in new LEED-certified professional office devel-
opment on Encinitas Blvd., close to 5 freeway,
Scripps Hospital, and public transportation. Free
parking, private bathroom, front desk area, and
additional storage space included. One to two
offices 11x14 are available full or part time. Af-
fordable lease rate in desirable area. Contact
Wendy Khentigan, MD, at (760) 845-0434 or at
wendykmd@aol.com. [646]
ACROSS FROM SHARP CHILDRENS HOS-
PITAL: Beautifully furnished, fully equipped
2,000ft2 office with five exam rooms. Share
with a part-time physician. Please call (619) 823-
8111 or (858) 279-8111. [385]
MEDICAL OFFICE SPACE (SCRIPPS ENCINI-
TAS CAMPUS): OB/GYN-type consultation
room and one to two exam rooms with staff,
receptionist, etc. Equipment is available at ex-
tra cost. Surgical center next door. Free parking.
Perfect for low-volume hospital campus con-
sultations one to five half-days per week. Email
sbrooksreceptionist@yahoo.com or call (760)
753-8413. [557]
OFFICE SPACE AVAILABLE: Office space at
the corner of 8th Ave. and Washington St. in Hill-
crest. Surgical center in building. Ample parking
and simple freeway access. Close proximity to
Scripps Mercy Hospital. Call (619) 297-6100 or
email rbraun@handsrus.com. [555]
PHYSICIAN POSITIONS AVAILABLE
PER DIEM/WEEKEND PHYSICIAN INDEPEN-
DENT CONTRACTOR: Temecula independent
diagnostic testing facility seeks physicians to
monitor patient examinations requiring con-
trast. Position requires availability of at least
two Saturdays a month. Typically scheduled
for nine-hour day shifts. Candidates must have
California license. Please contact Robert at (619)
819-6528 for more information, or submit your
CV via fax to (619) 342-4733 for immediate con-
sideration. [699]
URGENT CARE: Busy practice established in
1982 in East County seeks a part-time (with pos-
42 S A N D I E G O P H Y S I C I A N . o r g
sibility of becoming full-time) physician. Please
fax CV to (619) 442-2245. [698]
OB/GYN: Well-established, busy OB/GYN prac-
tice next door to Mary Birch Womens Hospital
needs part-time associate with option to tran-
sition to full time. Inquires (858) 560-6200.
[687]
PRIMARY CARE PHYSICIAN FOR VETER-
ANS HOME CHULA VISTA: The Veterans Home
Chula Vista is currently seeking an additional
primary care physician to provide medical care
for veterans. The Veterans Home Chula Vista is
a multi-care level facility with capacity for 400
residents consisting of three independent living
retirement units with 165 beds; a Residential
Care Facility for the Elderly (RCFE) assisted liv-
ing unit with 55 beds; and a Skilled Nursing Facil-
ity (SNF) with 180 beds. The tentative start date
is July 2009. This position requires experience
in adult primary care medicine and preferably
long-term care medicine. If you are interested
in a career with our agency, please contact Paul
Wagner, MD, at paul.wagner@cdva.ca.gov. [680]
FAMILY PRACTICE POSITION:
Solo Family Practice with partner
Position to replace retiring senior
partner
No nights, weekend call or
hospitalization
Full spectrum Family Practice
Well established patient base
Full time or part time (3 days minimum)
Upscale location and office
Call Peter Graham,
Broker 858-395-9928
Call Sally at 858-736-5818
SENIOR PHYSICIAN, HIV/STD/HEPATITIS
BRANCH, COUNTY OF SAN DIEGO: Are you
looking for a rewarding career that spans in-
dividual patient care and county-wide public
health program development? As the medical
director of the County STD clinic that provides
HIV screening, diagnosis and treatment for sex-
ually transmitted diseases, and hepatitis immu-
nization, the Senior Physician manages a team
responsible for providing excellence in clinical
services. We are looking for a candidate who has
strong leadership skills and the ability to work
collaboratively with team members. Functional
application of data, aptitude with technical writ-
ing and the desire to build bridges in the commu-
nity are also desirable skills. We require a license
to practice medicine in the State of California
and at least three (3) years of post-internship
training. Particularly suitable is a background in
Internal Medicine, Family Practice, Ob-Gyn, Urol-
ogy or Infectious Diseases. Please be aware that
availability to work flexible schedules at multiple
sites, including some evenings, is expected. If
you meet the above, we are interested in YOU!
Please visit www.sdcounty.ca.gov/hr to file an
application. [675]
| A p r i l 2 0 0 9
MOONLIGHTING PSYCHIATRIST WANTED:
Flexible 1+ weekends/month at Pomerado Inpa-
tient Geropsychiatric Unit. Must be board eligi-
ble or board certified. $200+/hr. Contact Jason
Keri, MD, at (619) 299-4374. [676]
PT/FT PSYCHIATRIST WANTED: To join re-
spected multi-specialty group serving nursing
homes. Office and hospital optional. Partnership
and growth opportunities. Highly flexible sched-
ule. $180k+. Contact Jason Keri, MD, at (619)
299-4374. [677]
INTERNAL MEDICINE PRIVATE PRACTICE,
UNUSUAL FLEXIBILITY, UNIQUE OPPORTU-
NITY: North San Diego County, part-time posi-
tion, looking for board-certified internist. If in-
terested, please call (619) 248-2324. [668]
NEUROLOGY POSITION: Position available
immediately for board-certified/board-eligible
neurologist in Mission Valley. Experience with
forensics or workers compensation preferred.
Physician must go out on medical leave and
needs coverage. This is a very busy practice that
does include some pain management. Currently
we have an MD with musculoskeletal experience
(fellowship at UCLA in acupuncture) and for-
eign graduate MD serving as PA to assist with
practice. Position has potential to evolve into
permanent position or partnership depending
upon compatibility issues. Respond to dovemd@
sbcglobal.net for further details. [667]
KAISER PERMANENTE CARDIOLOGY EPS
OPPORTUNITY: At Kaiser Permanente South-
ern California, we believe our achievements
are best measured by the health and wellness
of the community we serve. Thats why we pro-
vide a fully integrated system of care guided by
values such as integrity, quality, service, and, of
course, results. If you would like to work with an
organization that gives you the tools, resources,
and freedom you need to get the best outcomes
possible for your patients, come to Kaiser Per-
manente. For consideration, please forward your
CV to: Bettina.X.Virtusio@kp.org or call Bettina
at (800) 541-7946. We are an AAP/EEO employ-
er. http://physiciancareers.kp.org/scal. [665]
practice management
PRACTICE MANAGEMENT SER-
VICES/PRACTICE MANAGER/KEY
STAFF JOB SEARCHES: Let the
practice professionals find you the right
person. Plus, you are not identified. We
place the ads, receive the applications,
interview the better candidates, do ref-
erence checking and bring you the best
2 to 4 candidates for final interviewing.
We also do the salary and benefits nego-
tiation with the preferred candidate. We
know the medical office and can pinpoint
what you need. Reasonable fees.
Contact Regina Reading or
George Conomikes of Conomikes
Associates, Inc.; (858) 720-0379 or
email rreading@conomikes.com.
 NONPHYSICIAN POSITIONS AVAILABLE PRACTICES FOR SALE MEDICAL EQUIPMENT

MEDICAL ASSISTANT/BACK OFFICE: Busy
OB/GYN practice needs experienced MA to start
08/09. Competitive wage and benefits. Spanish
a plus but not required. Fax resume to (619) 298-
4250. [673]
PART-TIME PA OR NP: Small family practice in
Chula Vista, two blocks north of Scripps Chula
Vista Hospital, is seeking a bilingual PA or NP for
part-time employment. Please call Drs. Jenkin
or Tetteh if interested at (619) 804-7252. [669]
REGISTERED NURSE (RN): Family medicine
office in Torrey Hills seeking a full-time, experi-
enced RN. Previous clinical experience required.
Salary and benefits are negotiable. Please call
(858) 350-8100 or email rsum to admin@tor-
reyhillsfamilymedicine.com. [577]
PART-TIME MEDICAL ASSISTANT/BACK OF-
FICE: Two years experience required including
phlebotomy. Busy specialist office near Alvarado
Hospital. Submit rsums via email to dlpot-
ter22@hotmail.com. [576]
PHYSICIAN POSITIONS WANTED
MD SEEKING PART-TIME EMPLOYMENT: El-
derly MD in North San Diego with prior legal,
weight, etc., experience seeking part-time em-
ployment. Call (949) 492-0198. [651]
DEL MAR-AREA GENERAL PRACTICE: Prime
location, huge potential for practice expansion
in fast growing Carmel Valley community. Es-
tablished in 1990; terms available. Inquiries call
(858) 755-0510. [185]
FAMILY PRACTICE FOR SALE:
 olo practice with associate
S
 ell established 20 years, strong
W
patient base
900K yearly gross, no HMO
Very upscale location
Currently no nights, weekend call or
gical light, heavy duty casters, table lock, auto
hospitalizations
Beautiful office fully equipped
Moderate complexity lab, new digital
Xray
Slit lamp, Spirometry, computer read
ECG
Call Peter Graham,
Broker 858-395-9928
Call Sally at 858-736-5818
SMARTSOUND ULTRASOUND MACHINE: For
cellulite treatment, deep tissue massage, and
muscle pain and promotes post-operative
healing: $3,950. Item originally purchased for
$15,000. Machine is like new, was placed in
storage shortly after purchase, and in perfect
working condition. Willing to negotiate price.
Please call (858) 693-3000 for more informa-
tion. [695]
MEDICAL EQUIPMENT FOR SALE: Contour op-
erating table, plastic surgery components, now
Dexta surgical. Perfect for oral surgery, plastic
surgery, ENT dermatology. Built in mayo stands,
monitor brackets, equipment brackets, power
foot controls, arm boards, head rest, Burton sur-
trendelenberg, dual back rest position controls,
articulating back. A mobile operating room!
Contact Keith Wahl, MD, at kwahl@san.rr.com or
on cellular at (858) 518-2190. [681]
Place your
advertisement
here
Contact Dari Pebdani
at 858-231-1231
or DPebdani@sdcms.org

When times are good, you

should advertise.
When times are bad,
you MUST advertise.*
Advertise in the San Diego County Medical Society
2010 Pictorial Membership Directory

The SDCMS Pictorial Membership Directory is published annually and mailed to all member physicians (approximately
3,000). It is also available for purchase by non-member physicians and other interested parties. Advertising in the
SDCMS Pictorial Membership Directory is a cost-effective and profitable way to get referrals and put your message
in front of physicians, office staff, and patients who utilize this critical resource on a daily basis.

SDCMS Member Physicians Receive Color advertisements and premium positions are

25% off
limited and available on a first-come, first-served
basis. Contact Dari Pebdani today: 858-231-1231
or DPebdani@SDCMS.org
a d v e r t i s i n g r at e s
*From an article by American Business Media entitled Making a Recession Work for You.

A p r i l 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 43
 Hero for a Day
By Richard A. Brown, MD
Boy Slices His
Wrist on His
Snowboard
Five Hours Later
T
he phone rang. I ignored it. It
beeped a message. I ignored it.
I do not fiddle with my phone
on a ski lift. I figure that either the phone
or I will fall off. I knew what the call was
about anyway. Dinner that night. Ten
minutes later the ringer sounded again. I
no longer had a choice. I had to answer.
It was not about dinner. Not even close.
Given that I was not on call, I was not ex-
44 S A N D I E G O P H Y S I C I A N . o r g
pecting to speak to someone in the ER.
On the other end, a surgeon I know was
telling me that a 14-year-old had sliced his
wrist on his snowboard. His fingers had
no function and no blood supply. Would I
please come in and help? I was supposed
to be on vacation not working. Clearly,
I was going to do the case. To decide other-
wise would have violated who I think I am. I
am not going to lie. I had no desire on Earth
to tackle the problem. I knew time was criti-
cal and that I would have to push. I got an
ambulance to pick me up at the mountain
and drive me to the hospital. As I walked
to the OR, I was playing the usual mental
games. Sometimes things arent as bad as
described. This one was: 11 tendons, both
major nerves, and both major arteries.
Five hours later, the task was complet-
| A p r i l 2 0 0 9
ed. Everything was fixed. Blood was again
flowing. I was relieved and tired. Outsiders
assume that everything will always work
out. I know better. I was already trying to
figure out what I would do if I got a call the
next day telling me that the arteries were
clotted. Paranoia defines me. No such call
occurred. Instead I had three people phone
me to sincerely thank me for operating on
the boy. I had three other people give me
real hugs. The response was unexpected
and overwhelmingly gratifying. Medicine
is a complicated, perplexing, and at times
profoundly frustrating profession. Worth
it? Absolutely.
About the A u t ho r : Dr.
Brown, SDCMS and CMA member since
1993, is board certified in both surgery of
the hand and orthopedic surgery. He is
a member of Torrey Pines Orthopaedic
Medical Group, Inc.
Submit your
Hero for a Day
stories for possible
publication to
Editor@SDCMS.org.
Superior Standards.
From the business structure of this physcian
owned and governed company, to the
proactive approach to risk management,
CAPs priorities are consistent with
my own style of practice and
business philosophies.
Tammy Wu, MD

CAP District Council Member

The Cooperative of American Physicians, Inc. (CAP)

is the only physician owned and governed company whose
core product, Mutual Protection Trust, is Rated A+ (Superior)
by A.M. Best Company. Superior physicians are dedicated
to excellence. They should expect nothing less from their
medical professional liability provider.

For more than 30 years, CAP has rewarded the dedication of superior
physicians with superior protection for less. We keep our costs low
by keeping our standards high. Membership might not come easy,
but once you get in, you know youre in good company. To find out
more, call 800-252-7706, or visit www.superiorphysicians.com.

C ooperative of a meriCan p hysiCians , i nC . | 333 s. h ope s t ., 8 th f loor | l os a ngeles , Ca 90071

SAN DIEGO | ORANGE | LOS ANGELES | PALO ALTO | SACRAMENTO

The Mutual Protection Trust (MPT) is an unincorporated interindemnity arrangement among physicians authorized by Section 1280.7 of the California Insurance Code. Members do not pay
insurance premiums. Instead, they pay tax-deductible assessments, based on risk classifications, for the amount necessary to pay claims and administrative costs. No assurance can
be given as to the amount or frequency of assessments. Members also make a tax-deductible Initial Trust Deposit, which is refundable according to the terms of the MPT Agreement.
 $5.95 | www.SANDIEGOPHYSICIAN.org
PRSRT STD
San diego County Medical Society U.S. POSTAGE
5575 RUFFINROAD, SUITE 250 PAID
SANDIEGO, CA 92123 DENVER, CO
PERMITNO. 5377
[ RETURNSERVICEREQUESTED ]

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