PANDEMIC H1N1 Influenza - Oregon Medical Association

MEDICINE in Oregon

A publication of the Oregon Medical Association

Fall 2009 Policy • Community • Practice

PANDEMIC

H1N1 InfluenzaWhat Physicians

Need to Know

Physician Liability Protections during Disasters or Emergencies

Safety Net Clinics: Critical to Public Health

MEDICINEin Oregon

Volume 2, Number 4 Fall 2009

POLICY COMMUNITY PRACTICE

Published quarterly by Oregon Medical Association 11740 SW 68th Pkwy, Ste 100Portland, OR 97223(503) 619-8000 • fax (503) 619-0609www.theOMA.org • [email protected]

Editorial Advisory BoardCarla McKelvey, Physician EditorMonica Wehby Peter BernardoNancy Boutin Evelyn FordMike Crew (of counsel)

OMA StaffJo Bryson Betsy Boyd-FlynnJennifer Nordgaard Ryan JamesReina O’Beck

SubmissionsWe welcome and encourage our members to contribute to Medicine in Oregon.

For more information, contact Betsy Boyd-Flynn at (503) 619-8000 or [email protected]

Advertising & Design byLLM Publications, Inc.8201 SE 17th Ave, Portland OR 97202(503) 445-2220 • (800) 647-1511fax (503) 655-0778www.llm.comPresident | Linda PopeGraphic Design | Heather WhiteAdvertising Sales | Snow Blackwood

Joseph Madigan

On the CoverDeciduous trees display their best colors when late summer is dry and autumn has bright days and cool nights. Most leaves fall from trees because the ends of the branch are sealed off near the leaf stem to protect the tree through the long winter months.

© 2009 by the Oregon Medical Association. All rights reserved. No part of this publication may be reproduced or transmitted in any form by any means, electronic or mechanical, including photocopy, recording, any information storage or retrieval system, without permission from the publisher.

Preparing for the Worst: Doctors & Disaster

4 FROM THE PRESIDENTReformation Recommendations

6 FROM THE DESK OF JO BRYSONMake Sure You Have a Plan

14 FEATUREPandemic H1N1 Influenza— What Physicians Need to KnowBy Oregon Public Health Division staff

PLUS Frequently Asked QuestionsOregon Public Health Division

PLUS Where Can Health Care Providers Go for More H1N1 Information?

25 IN-HOUSE COUNSELPhysician Liability Protections during Disasters or EmergenciesBy Annabel Lucas, JD

28 ON MY MINDMaking Sense of Disaster PreparednessBy Mark Gilbert, MD

PLUS...Pandemic H1N1 Frequently Asked Questions

14PAGE

Also Inside

MEMBERSHIP MATTERS

5 New and Reinstated Members

8 Safety Net Clinics Critical to Public Health By Jennifer Nordgaard

9 Upcoming Events

10 Advocacy Corner—Red Flags vs. Breach Notification Rules

By Chris Apgar, CISSP

12 OMA ALLIANCEPrescription Drug Take-back Program

21 ADVOCACY IN FOCUSMichigan Practice Profits from HITBy AMA Staff

23 IN THE OFFICECareer Transitions—A Life-Long TripBy Gary Schaub

30 IN THE SPOTLIGHTTaking Control with Health Education By Kristin Jordan, RN, MPH

PANDEMIC


Need to Know

Interested in contributing to Medicine in Oregon magazine?

503-619-8000 or [email protected]

Peter A. Bernardo, MD

Reformation Recommendations

Here’s what I think.

What about you?

I invite you to visit

the OMA’s new blog,

accessible through

www.theOMA.org and

begin the conversation.

From the President

Peter A. Bernardo, MD is president of the Oregon Medical Association. He is a general surgeon in private practice in Salem and has been an OMA member since 1992.

DURING THE MONTH OF August, debate over health care reform heated up with the summer

temperatures, and it cooled down as fall began. We have seen tempers flare as opinion-makers and politicians on the left and the right make claims and counter-claims that inflame and confuse. What seems to be clear is that everyone has an opinion—and even among physicians, those opinions vary widely.

I’d like to know more about what our members think. So, I’ll start the dialogue by offering my own ‘take’ on things. A word of warning: what I write here may anger you, or may unnerve you, but it’s meant to represent ‘out of the box’ thinking, and to get you thinking that way, too. We can’t solve a problem this big with solutions we’ve tried in the past. I hope this will be one voice in a conversation among our members.

As a private practice general surgeon in Oregon, I have my own perspective on our health care system. In Oregon, we have a strong tradition of cost-effective quality health care. There are clinics, IPAs, and hospital systems in this state that can be models for the nation. There is a disparity in care nationwide. That is not surprising given the size of our country and the level of cultural and economic diversity. From an economic standpoint there are “perverse incentives” in our system, but I take umbrage at the accusation that those incentives somehow affect how I treat patients.

Whatever change comes to our health care system it must reflect the needs and traditions of American society. Comparisons to other countries are interesting, but in the end, they are not helpful. Canada, Britain, Japan, France, and Germany all have good health care systems. Those systems though, reflect the structure and culture of those societies. An American

system must balance personal freedom and choice with personal responsibil-ity. It must temper capitalism with government intervention. It must allow everyone to pursue happiness, and to reap the rewards of their hard work and talent, while making sure that those less fortunate members of society are cared for.

In the short term, we need to find a way to provide basic health insurance and health care for all Americans. Thereafter, we need to improve the overall provision of health care and to control costs. In the long-term, we need to improve the health of our society. The following recommendations are sure to challenge the opinions of almost everyone. If so, then I have done a good job of balancing the needs of the many against the desires of the few.

Insurance ReformGuaranteed issue, no pre-existing conditions, community rating, standardized benefit plans, individual mandate with sliding scale tax credits or premium support for individuals and families from 150–400% FPL, national standards for coding and billing; remove individual state barriers to insurance; tax employer-sponsored plans above the cost of the basic benefit package.

There are many high-performing insurance companies and systems that deliver excellent cost-effective health care. Preserve those companies and correct the excesses of the others.

Expand MedicaidCoverage for all individuals below 150% of the federal poverty level, uniform nationwide basic benefit package, designated funding through a VAT, establish a national formulary with negotiated prices, establish regional managed care so that health care providers (physicians and

4 • Medicine in Oregon

hospitals) are financially at risk for the health of their patients.

Medicaid is intended to cover the poorest of our citizens. They have no resources and should not be expected to pay any significant portion of their care. These are the people who require access to a basic benefits package.

Fix MedicareMeans testing for patient premiums, equalize reimbursement across the U.S., fix the SGR formula, establish a national formulary with negotiated prices, establish regional managed care so that health care providers (physicians and hospitals) are financially at risk for the health of their patients, expand comparative effectiveness research and the discussion of marginal benefit of treatments, limit payments on new technology and treatments until benefits are established.

Medicare was established to provide medical care for the elderly poor. It is a great system that provides care on a consistent basis to all older Americans. It is also facing bankruptcy. Baby Boomers make up the most affluent segment of our society. They should continue to pay some portion of their premiums. There are wide variations in the quality and cost of that care. Ten percent of Medicare recipients use 66% of the resources. Figure out why.

Tort ReformEstablish health courts with limits on non-economic damages and contingency fees. Sixty percent of each liability premium dollar goes to lawyers and administration. Defensive medicine adds 10–15% to the cost of health care. Find a better way.

Train More PhysiciansExpand graduate medical education programs and community health programs, encourage primary care specialties including general surgery and psychiatry, distribute more uniformly throughout the U.S.

Nurse practitioners and physician assistants are an important part of the health care team, but medical care is more complicated then ever before and that requires more physicians.

Expand Public HealthPhysical education, health and nutritional education, increased taxes on alcohol, tobacco, soda, and fast food.

Accidental death, homicide, drug and alcohol abuse, smoking and obesity are more important determinants of our national health than the nature of our insurance system. Find a way to make our society healthier. In the long term, it is the only realistic way to control cost and improve outcomes.

Joining the CircleOMA thanks those members who have paid their dues, and welcomes the following new members and those who have reinstated their membership with the OMA.

Gloria Alexander, MDZakir Ali, MDRichard L. Alley, MDAmber R. An, DODaniel R. Anderson, MDKevin Arce, MDAnthony M. Archer, DODiaa A.N. Bahgat, MDJason Eugene BahkDavid Jason BaileyCraig A. Baldenhofer, MDCarl A. Barbee, MDElizabeth Anne Barbieri, MD Caroline Mary Floyd BarrettTerri K. Benner, PAGary Ryan Berger, MDLloyd D. Biby, MDDarcy L. Blanchard, DOPeter S. Bogard, DOMarcus A. Braman, MDNicolas D. Brown, MDGregory D. Byrd, MDCoralia B. Calomeni, MDGregory V. S. Camp, MDValerie Margaret CarlbergDierdre Julia CavanErin Dahlin ChamberlainEric C. Chang, MDRanjana Chauhan, MDLaurie Chern, MDMehee Choi, MDDustin Christiansen, MDAmity K. ChuPaige E. Clark, MDChristine G.S. Clarke, MDGeorge A. Clarke, MDWilliam E. Connor, MDShannon K. Corcoran, PA-CMarka R. Crittenden, MDKaren Elaine

Crocker-Wensel, MDMerlia Thomas CurryNeisha A. D’Souza, MDLee B. Daniel, MDJames L. Davidian, MDJeffrey W. Degen, MDPamela G. Demian, MDJohn M. Dempster, Jr, MDClover N. Dill, MDTroy H. Dillard, MDHau Duc DoC. William Dronkowski, MDScott A. Dyer, DOJared Eller, DOJenna Beth-Marie EmersonMaria M. Emerson, MDMichael S. Englehart, MDMichael F. Fadell, MDFarnaz Dana Fakhari, MDMona G. Flores, MDJessica Diane FowlerMatthew C. Frank, MDYvonne S. Fried, MDHarminder P.S. Gandhok, MD

Sandra K. Garrard, MDMatthew R. Gee, MDRaymond G. Good, DODavid A. Goodwin, MDLori L. Goranson, MDDavid R. Goshorn, MDLynn E. Gower, DOLisa C. Grant, MDRyan S. Griffiths, MDChristina Grucella, MDMichelle C. Hall, MDJeffrey Leonard HalleckJennifer O. Hamilton, MDEmily Lynn HansonAmy Jean HarlowManya B. Helman, MDJoselyn S. Hill, MDIngrid M.S. Hogberg, MDMarc R.J. Houston, DOLisa A. Howe, PABenjamin F. Hudson, DOConstance

Hume-Rodman, MDQuyen T. HuynhSeth D. Izenberg, MDConstance J. Jackson, MDLoren E. Jenkins, MDJason R. Jensen, MDJack C. Ji, DOClotilde A.

Johnson-Beale, MDKatherine S. Johnston, MDEmily P. Jones, MDThatcher Mac JonesStephen M. Jovonovich, MDCrispin L. Juguilon, Jr, MDHyunchul Jung, MDColin Daniel KennedyHolly L. Keyt, MDFarbod KhakiJennifer G. Kim, MDKenneth P. Kim, MDRobert D. Kim, MDShane C. Kim, MDMartin Mark Klos, MDRichard J. Koesel, MDPeter Kosek, MDMichael A. Kuhne, MDChristopher C. Kyle, MDPetey Laohaburanakit, MDJon LarrabeeThomas Lee, MDPaula M. Lee-Valkov, MDJustin J. Leitenberger, MDVirginia C. Leslie, MDMelindres J. Lim, MDSyrone LiuJennifer J. LoweJoshua E. Lubek, MDJacob Thomas LutyHeather A.

Mackay-Gimino, MDJeffrey P. Mako, MDDaniel Scott McBride, Jr, MDGeoffrey W. McCarthy, MD

Fall 2009 • 5

Magazine Submission Guidelines

We welcome submissions from our members, including opinion pieces, essays about your practice, or visual art. We do not offer payment for published work, but can provide additional copies of the magazine in which your work appears. If you are interested in writing but do not have a clear idea or a specific topic in mind, you may wish to contact a member of the editorial advisory board or the staff editor. They may be able to assign you a topic or make suggestions for content we are seeking for a particular issue.

Get a sense of what is planned by viewing the editorial calendar for the year, which is kept up to date on the OMA website at www.theOMA.org/MiO. Submission deadlines and tentative themes for each issue are as follows:

Dec. 4: Winter 2010; Quality & Performance in Practice March 5, 2010: Spring 2010; Military and Medicine

Jun. 4, 2010: Summer 2010; Medical Education Sept. 3, 2010: Fall 2010; Reform Refresh

Send your submissions electronically to [email protected]. Written submissions should be sent in rich text format or MS Word 2003. Any accompanying photos or illustrations can be sent either on CD or via e-mail. Please note these must be high-resolution files, 300 dpi or higher. We have a 6MB size limitation on e-mail we can receive. Include a brief (25 words or fewer) biographical note, including your specialty, where you practice and (optionally) how long you have been a member of OMA. Works of visual art can be mailed on CD or e-mail, or contact Betsy Boyd-Flynn to arrange an in-person meeting.

Make Sure You Have a Plan

Joanne K. Bryson, CAE

From the Desk of Jo Bryson


IN SPRING OF THIS YEAR, the World Health Organization raised the H1N1 pandemic alert level to Phase

5, informing us that human-to-human spread of the virus had occurred in at least two countries and showed a strong signal that a pandemic was imminent. The current WHO phase of pandemic alert is now at Phase 6, alerting that a global pandemic is underway.

Flu viruses thrive everywhere and are constantly changing. Only three conditions must be met to have a pandemic occur:

� A new disease emerges to which we have little or no immunity

� The disease is infectious to humans

� It spreads easily among humans

This isn’t the first time we have experienced a pandemic and it will most likely not be the last. In the 20th century alone, pandemics occurred three times: 1918, 1957–58, and 1967–68. In 1918, by the time the flu pandemic came to a close, over one-third of the world’s population (more than 500 million people at the time) had been infected, with an estimated 675,000 deaths in the United States alone.

The reported number of H1N1-related deaths and reported cases actually understates the total number of people affected by the virus, given

that countries were not required to test and report individual cases. As of September 1, 2009, the Centers for Disease Control and Prevention re-zeroed its cumulative case counts and is now combining seasonal influenza and H1N1 cases. In Oregon, all influenza-related deaths as well as hospitalizations are reportable as of September 1.

Preparation and prevention are key factors. Below are critical pandemic preparedness steps for physicians and other health care professionals

(adapted from the American Medical Association):

� Be knowledgeable of pandemic preparedness and response plans for your institution and community. Routinely review existing in-house emergency plans, policies and procedures.

� Work with local fire, police, emergency medical services, emergency management, and public health agencies to coordinate pandemic response planning. Learn how your facility is integrated into community pandemic plans—know what is expected of you.

� Learn the incident command structure for your facility and community; know how to become involved, particularly when responding as a volunteer.

� Routinely participate in disaster drills and exercises to test pandemic plans; practice flexibility.

� Participate in continuing education and training programs to enhance your knowledge, competency and willingness to respond to an emergency or mass illness situation.

� Know the person in charge of pandemic planning at your facility and in the community (if these positions do not exist, advocate for such appointment).

� Learn your facility’s emergency com-munications plan; identify the point person for working with the media.

� Know your roles and responsibilities in a pandemic response situation—and stay within them.

� Know how to contact local and state health and law enforcement agencies.

� Ensure inclusion of mental health support for affected individuals, families and responders.

� Ensure that pandemic preparedness and response plans address the unique health care needs of children and other vulnerable

populations, particularly those with special health requirements.

� Enhance hospital preparedness by developing standard operating procedures for the management and treatment of infected and exposed persons.

� Maintain reference materials and create “quick reference guides” and algorithms to facilitate the emergen-cy triage and treatment of all people that arrive at a medical facility during the pandemic. Training tools should be developed to facilitate the recognition and quick reaction of emergency personnel in assessing sick persons brought to the facility.

� Designate resource physicians for each medical facility who will ensure that other health care professionals designated to treat infected patients know how to use available “quick reference guides,” algorithms and treatment protocols.

� Know the requirements for labora-tory support and confirmation.

� Equip emergency medical services personnel and response vehicles with pediatric-specific equipment and medications.

� Be aware of available professional and public resources and how to access them immediately and in various ways.

� Be aware of mechanisms for dissemi-nating timely and accurate informa-tion to hospital employees, their families, and the public (e.g., one-button broadcast distribution lists, redundant communication plans).

� Ensure effective security systems (e.g., badge systems) that allow access to your site for key response personnel.1

Educate your patients � Protect yourself by getting

vaccinated.

� On Sept. 15, 2009 the FDA approved the H1N1 vaccine after rigorous testing. The vaccine is expected to be available throughout Oregon in early October. The vaccine will be given as a shot or a nasal spray.

� Prevent the spread of germs.

� Cover your mouth and nose when you cough and sneeze (use your sleeve or a tissue).

� Wash your hands, and do it often. Soap and water are best but when they are not available, use alcohol-based hand gel or disposable wipes.

� Don’t touch your eyes, nose or mouth.

� Stay home when you’re sick or have flu symptoms.

Remember…being prepared and having a plan puts everyone a step ahead of the game.

OMA has collected several sources of information for its members, which can be found at www.theOMA.org/h1n1flu. For the most up-to-date information, as well as to order “Stop the Spread of Germs” posters, go to www.flu.oregon.gov.

Vanessa A. McDonald, DOJanhavi Meghashyam, MDJon M. Messinger, MDJanelle M. Meyer, MDMichelle R. Mills, MDSounak Nick Misra, MDJeffrey L. Moller, MDChristie J. Moore, DOKathryn D. Moyer, MDRichard J. Myers, MDRichard Scott Nelson, DOWenn J. Ng, MDPhong X. Ngo, MDMichelle B. Noelck, MDNorth J. Noelck, MDTimothy O. Noreuil, MDMorgan Gregory O’ConnorMichael J. O’Neill, MDGlen Sean O’Sullivan, MDJeffrey M. Oblad, MDAndrew H. Oh, MDRobert L. Oldham, MDDaniel N. Packard, DOJessica Marie PageJanet D. Paquette, MDJocelyn A. Park, MDKevin W. Parks, MDMonina F. Pascua, MDPrabhakar Patel, MDJustin B. Pavlovich, MDNatasha Pereira, MDCharles J. Petit, MDThu Quynh PhamKristine K. Pierce, MDAlan S. Polackwich, Jr, MDTheerapol

Prasertsuntarasai, MDAvinash N. Ramchandani, MDAmeen I. Ramzy, MDPaul Steven ReynoldsPiper K. Rooke, MDKenneth D. Rose, MDLeigh Saint-Louis, MDKelli D. Salter, MDLiza D. Samson, MDAlan B. Sandler, MD

Joseph P. Schenck, MDBarry L. Schlansky, MDShawn D. Schumacher, MDGarrett R. Scott, MDSarah L. Scott, DOMaulin P. Shah, MDStuart T. Sharp, PA-C Taylor Marilyn ShekellJoseph E. Sherrill, II, MDDerek S. Shia, MDMia E. Skourtis, MDCristian M. Slough, MDAndrea C. SmeraglioMark D. Smith, MDJoseph F. Sobanko, MDBarbara J. Spezia, MDNicholas J. Spoerke, MDJustin Lee StimacJonathan P. Stoehr, MDKevin B. Stout, MDGlen R. Stream, MDMichael Su, MDLisa C. Sullinales, MDDavid C. Swiderski, MDCourtney E. Takahashi, MDFares Ricky TavangariLance T. Taylor, MDNicole Vanderheyden, MDDavid M. Volkov, MDTammy L. Washut, MDSarah N. WebberIlana M. WeinbaumFrancis J. Welch, IV, PA-CLindsay Michelle WengerJacob Lee WesterMarguerite Davis Wilkins, MDDanielle C. Williams, MDDennis D. Winner, MDJohn W. Winward, DOPouya YaghmaieRenata Yang, MDRussell J. Young, III, MDAlexi P. Zemsky, MDWeiya Zhang, MDKaren Anne Zink, MDChrisanthy A. Zowtiak, MD

1 Pandemic Influenza – A primer and resource guide for physicians and other health professionals. American Medical Association and National Disaster Life Support Foundation

UNPREPAREDDon’t get caught

When disaster strikes, the ability to keep providing clinical services during and after the event depends on being prepared. With an emergency plan in place and the right information to make rapid decisions, you could save both your health care business and the lives of your patients.

What to do Before, During, and After an Emergency or Disaster: A Preparedness Toolkit for Office-Based Health Care Practices gives health care professionals the tools they need to be ready for the unexpected. Make sure you have an organized course of action if a catastrophic event occurs—order your Preparedness Toolkit today!

The Preparedness Toolkit and other valuable AMA resources are available to OMA members at special discount prices. Visit www.theOMA.org/publications for pricing and ordering information.


Membership Matters

Essential Health Clinic Brent Kimberly, MD a hospitalist at Providence St. Vincent Medical Center, heard about the Essential Health Clinic through a colleague, and began volunteering at its Hillsboro location nearly two years ago. The Essential Health Clinic, with a second location in Tigard, provides free urgent health care to uninsured individuals and families in Washington County. The clinic’s main focus is to identify and treat urgent medical problems, such as asthma, respiratory infections, urinary tract infections and minor injuries before they become serious or chronic illnesses.

Not only does Dr. Kimberly volunteer his time at the clinic approximately one evening a month, he has recruited several of his fellow St. Vincent hospitalists to volunteer on a regular basis as well. “The hospitalist program at St. Vincent had recently implemented a new scheduling program, which makes it easier to see when you’re scheduled to work,” says Dr. Kimberly. By including volunteer time at the Essential Health Clinic into the scheduling program, more of his colleagues began to volunteer as well. “A big part of getting people to volunteer is just making it as easy for them as possible,” says Dr. Kimberly.

SAFETY NET HEALTH CARE CLINICS play a vital role in overall public health efforts by providing medical care to low-income, uninsured patients in Oregon. These clinics are not only necessary during tough economic times or when disaster strikes, but provide access to essential medical care for some of Oregon’s most vulnerable

population. Meet two OMA members who give back to the community through their work at safety net clinics.

Experiencing a devastating natural disaster firsthand gave Don La Grone, MD, a deeper appreciation for the importance of safety net clinics, particularly when an area is struck by disaster. “I was a busy, practicing pediatrician in southern Mississippi when Hurricane Katrina hit in 2005,” says Dr. La Grone. “We were cleaned out. We lost nearly everything— our home, one of our clinics,” Dr. La Grone continues.

Two days after the storm, he volunteered in an emergency clinic treating injured patients, and realized how much he enjoyed just seeing patients and providing care. He found it refreshing not having to deal with insurance issues and some of the other hassles of running a medical practice.

“After much soul-searching, my family and I decided we wanted to move back to Oregon, where I had trained,” says Dr. La Grone. “We moved to Portland in 2008. I decided after many years of a demanding pediatric practice, I was ready for something less stressful, where I could work less and have more time for my family,” says Dr. La Grone. “I also realized I wanted to give back to the community, and get back to the basics of providing care to patients.”

The Children’s Community Clinic, located in NE Portland, had been closed for six months when Dr. La Grone stumbled upon it in the winter of 2008. At the time, the clinic didn’t have any providers. He volunteered to serve as its medical director and see patients two days a week.

The clinic has since grown, and is now open five days a week and provides primary care to patients from birth to age 21. “We’ve recruited several more pediatricians, including a pediatric cardiologist, who volunteer their time seeing patients one or two days a week,” explains Dr. La Grone. “We’re also in the process of finalizing an adolescent GYN clinic.”

Dr. La Grone has seen several chilling examples of what can happen to young patients who have no insurance. “It’s incredible that right in the middle of a city like Portland, with a very sophisticated health care delivery system, I’ve seen patients almost die due to a lack of insurance.”

“The need for safety net clinics is great,” concludes Dr. La Grone. “The number of patients the Children’s Community Clinic serves is increasing, and it will only continue to rise.”

Children’s Community Clinic

Critical to Public HealthBy Jennifer Nordgaard

Safety Net Clinics

“The clinic is packed every night. There definitely is a need.”

UPCOMING eventsOMA Headquarters11740 SW 68th Pkwy, Ste 100, Portland(503) 619-8000 • www.theOMA.org

Fall 2009 • 9

Executive Committee Meetings

Nov. 19, 4pm, OMA HeadquartersDec. 10, 4pm, OMA HeadquartersJan. 14, 4pm, OMA Headquarters

OMA Board of Trustees Meeting

Jan. 30, 9am, OMA Headquarters

Risk Management SeminarsBasic Training in Risk Management

11am–2pm, OMA HeadquartersNov. 18 or Dec. 2 or Dec. 12

Risk Management for Medical Office Personnel

Nov. 6, 12–4pm, OMA Headquarters

Advanced Training in Risk Management

Each seminar held at OMA Headquarters

Nov. 7, 8–11amNov. 18, 7:30–10:30 amDec. 2, 7:30–10:30 amDec. 12, 7:30–10:30 am

Coming Soon 2010 Loss Prevention Schedule

WorkshopsFor more information on OMA workshops, visit www.theOMA.org/workshops

Practice Management Series Nov. 17–19, OMA Headquarters

Nov. 17: Treating Patients Right—Tact, Courtesy and Etiquette in the Medical Office, 9am–12pm

Nov. 17: Preventing Embezzlement and Catching Money Errors, 1–4pm

Nov. 18: Honing Leadership, Teamwork and Management Skills, 9am–4pm

Nov. 19: Physician Productivity Best Practices—Raise Your Output and Control Your Time, 9am–4pm

Oregon Academy of Otolaryngology— Head and Neck Surgery, Inc., Fall Combined Meeting/DeWeese Lectureship

Nov. 6, Governor Hotel, Portland

Lane County Medical Society Monthly Dinner Meeting

Nov. 13, Eugene Hilton

Oregon Pathologists Association Dinner/Membership Business Meeting

Nov. 20, OMA Headquarters

Oregon Pathologists Association Scientific SeminarNov. 21, St. Vincent Medical Center, Souther Auditorium

American College of Emergency Physicians— Oregon Chapter Winter Conference

Jan. 31–Feb. 3, Sunriver Resort and Spa

Non-OMA Events

“If you can remove the hurdles, and just make it a part of their schedule, it makes it much easier to do.”

To accommodate volunteer staff and their work schedules, the urgent care clinic opens at 6:00 pm. People are usually lined up and waiting to be seen long before then. On average,

Dr. Kimberly sees about eight patients per night. “We see some very sick people here. They don’t have insurance or money for prescriptions.”

“It’s a good experience. I see patients with medical problems I wouldn’t normally see in my hospital practice. It gives me more clinic exposure with a different patient population,” says Dr. Kimberly. He concludes, “The clinic is packed every night. There definitely is a need.”

•These are just two examples of the many safety net clinics located throughout Oregon. The Oregon Primary Care Association lists more information on its website at www.orpca.org. For more information about the Children’s Community Clinic, contact Dr. Don La Grone at [email protected]. For more information about the Essential Health Clinic, visit www.essentialhealthclinic.org. Finally, look for additional volunteer opportunities each month in the Classifieds section of OMA’s monthly newsletter, STAT or on the last page of this magazine.

•Jennifer Nordgaard is the marketing coordinator at the OMA.


WHEN MORE THAN ONE significant regulation impacts a physician’s practice

at the same time, it can be confusing. Practices are required to comply with the Red Flags Rule and the new Breach Notification Interim Final Rule at nearly the same time. While there are practical ties between the two rules, they are distinctly different and will have a greater impact on some practices than on others.

Red Flags RuleThe Red Flags Rule is effective August 1, 2009 but will not be enforced for medical practitioners until November 1, 2009. The purpose of the Red Flags Rule is to require “creditors” (in the case of practices, this includes those that collect a co-pay from a patient and payment from a public or private health plan, or bill the health plan and then bill the patient) to implement an identity and medical identity theft protection program. From a practical perspective, most practices implemented similar safeguards after the Oregon Identity Theft Protection Act of 2007 was implemented.

Simply put, practices need to formally identify potential flags that indicate someone is accessing patient information without authorization, or if an individual is attempting to seek care using someone else’s name. Another purpose of the Red Flags Rule is to avoid the requirement to notify patients of any breach of their health or demographic information. It

is a preventive approach to protecting patients’ privacy.

Breach Notification RuleThe Breach Notification Interim Final Rule was published August 24, 2009, and practices needed to comply with the rule by September 23, 2009. This rule represents the other side of the Red Flags Rule. It is reactive and spells out the requirements if a breach of patient information occurs. It is similar to, but much broader than, the Oregon Identity Theft Protection Act of 2007. While it only applies to covered entities and business associates, it requires notification if any protected health information (PHI) is inappropriately disclosed.

In contrast to the provisions for breach notification under Oregon law, the new federal provisions mean that practices do not have the luxury of reverting to a substitute method of notifying individuals if the cost of no-tification is greater than a set amount or the number of patients affected is above a certain number. All individu-als affected must be notified by first class mail (or e-mail if that is the indi-vidual’s choice of communication). In some cases, an additional substi-tute notice is required (e.g., when the practice does not have current contact information for ten or more individuals and when the breach involves 500 individuals or more).

Operating within the RulesNeither rule requires the creation of new policies and procedures. The Red

Flags Rule requires the adoption of a Red Flags Rule umbrella policy to demonstrate compliance with the Red Flags Rule. The rule does, however, require changes to a practice’s risk analysis policy and procedure; the identification of red flags as part of the risk identification needs to be added. It also requires adding new duties to the practice’s security incident response team of investigating identified “red flags.” Finally, it requires practices to update their privacy and security training material in order to educate their workforce about what to look for with respect to “red flags” and to whom to report suspected “red flags.” Again, the Red Flags Rule only requires the implementation of one new policy and procedure.

The Breach Notification Interim Final Rule is similar. It doesn’t require the implementation of any new policies and procedures. It does, however, require ensuring breach notification is part of the documented mitigation phase that is a part of investigating a security incident reported to the practice’s security incident response team. It also requires expanding practices’ existing breach notification policy and procedure to include all PHI and the new notification requirements (such as providing notice to the US Department of Health and Human Services immediately if the breach involves 500 individuals or more).

OMA members can access information and template policies and procedures

Red Flags vs. Breach Notification Rules

By Chris Apgar, CISSP

Advocacy Corner

Fall 2009 • 11

for both rules at www.theOMA.org/practicemgmt. An updated breach notification policy and procedure has been added, as well as a template business associate contract (for new and for renewing business associate contracts) and contract addendum (for existing business associates). Both include the required Red Flags Rule and the breach notification language.

What is important to remember about breach notification is that practices need to notify their patients of any breaches as soon as feasible, but no later than 60 days from the date of the breach.

What was clarified with the publication of the interim final rule includes:

� Practices have up to 60 days to notify patients from the date their business associates inform them of a breach and provide the information

necessary to notify patients of the business associates’ breach.

� If substitute notice is required because a practice does not have up-to-date contact information for ten or more patients, a prominent notice needs to be posted on the practice’s website for a minimum of 90 days. (Practices can elect to publish a substitute notice through major media instead, if they so choose.)

� A toll-free number must be activated for no less than 90 days if substitute notice is required because up-to-date contact information is not available for ten or more patients. (This is the case whether notice is made via the practice’s website or through major media.)

� For all breaches involving fewer than 500 patients, a breach log needs to be maintained with all of

the details about the breach and all individuals affected. The log needs to be reported to HHS no later than 60 days from the end of the reporting year (likely calendar; the contents or format of the report has not yet been finalized.)

It can get confusing and take up significant staff time when major rules such as these are effective close to the same time. The Red Flags Rule is proactive and the Breach Notification Interim Final Rule is reactive. What is most important to remember is the need to update current policies and procedures to include the new rule requirements, versus creating a set of new policies and procedures for each rule.

Chris Apgar is a nationally-recognized consultant on privacy and security issues. He can be contacted at [email protected].

By Leanna Lindquist, President

OMA Alliance

Leanna Lindquist, RN, is a recovery room nurse married to past OMA President David Lindquist, MD, of West Linn.

In the Works:

Prescription Drug Take-back Program

Prescription Drug Abuse High Among TeensPartnership for a Drug-Free America reports that the average starting age for a student to begin abusing prescription drugs is 12 years old. They are trying or using prescription drugs for non-medical reasons. Many of them think these drugs are safe because prescription pills have legitimate uses, but taking them without a prescription to get high or “self-medicate” can be as dangerous—and addictive—as using street narcotics and other illicit drugs. According to a Partnership for a Drug-Free America study, 20 percent of high school students have abused prescription drugs, including pain-management drugs and stimulant medication. Prescription drugs are easier for children to get than are illicit drugs; they find them mostly in their family’s medicine cabinet, but also from friends’ homes, internet pharmacies or classmates.

Accidental Drug Use Can Lead to Death in ChildrenA recent study from the nation’s poison control centers shows a frightening trend in the number of accidental poisonings or deaths from young children who somehow injest popular painkillers.

What Parents Can Do � Monitor your medicine cabinets.

Count how many pills you have and make note of the date when you should expect to refill your prescriptions. Be aware that children may obtain drugs from medicine cabinets while visiting friends or family. Restrict the availability of these substances within your home.

� Talk with your child about drug use. Help him or her understand that

misused prescription drugs can be just as dangerous as street drugs. When used in combination with other substances, such as alcohol, prescription drug use can be fatal.

� Attend a “drug take-back program” to rid your home of unneeded or expired medications.

Disposing of Unwanted Pharmaceuticals What should we do with outdated or unwanted pharmaceuticals? For decades, disposing of medications down the drain or toilet was recommended to keep children and pets from ingesting them. The effects of that practice have now come to light, with trace amounts of prescription drugs turning up in the water supply

nationwide. Many people have and will continue to throw expired medication in the garbage. We now know, however, that medicine can actually get into our soil, creating an environmental hazard.

The current recommendation is to take old pills and pulverize them, mix with water to dissolve or mix with coffee grounds or kitty litter. Return them to their child-safe container, mark out personal information on the label, and place the sealed container inside several thick zip lock plastic bags or a thick plastic container. This can now be tossed into the household trash. There is still a chance the medicine can leak out and present a hazard. This is not a perfect solution, but at this time it is considered the best management practice.


Every day, 3,300 children begin experimenting with prescription drugs.

70% of children who abuse prescription drugs admit to getting

them from family and friends.

Fall 2009 • 13

Prescription Drug Take-back ProgramIn a grassroots effort, the OMA Alliance and the OMA are working with Oregon Partnership and other groups to create a drug turn-in event in March 2010. This will be a statewide one-day event that will provide an opportunity for community members to take their unwanted drugs to a central location for incineration.

It is clear that an effective disposal mechanism for excess pharmaceuticals is needed in the state of Oregon. Until that time, our program will educate the public, safely rid homes of unwanted drugs and call attention to this issue.

If you would like to be part of this program to ensure that a Prescription Drug Take-back Program occurs in your community, please contact Pat Webster, OMA Alliance at (503) 619-8000.

By Oregon Public Health Division Staff

Oregon’s New Reporting LawAs of Sept. 1, 2009, an emergency Oregon Administrative Rule mandates reporting by physicians, labs, and medical facilities of all patients hospitalized with laboratory-confirmed influenza to the local health department for the county in which the patient resides. Please include patient name, home address, phone number, date of birth, gender, and date of hospital admission. Race and ethnicity would be appreciated as well.

This rule remains in effect for 180 days from Sept. 1, at which time a permanent rule may be filed.

Epidemiology of Pandemic H1N1 InfluenzaOn April 15, 2009, the Centers for Disease Control and Prevention (CDC) confirmed pandemic H1N1 influenza in a US patient. The apparently promiscuous virus, which has genetic sequences in common with North American avian flu, human seasonal flu, and both Eurasian and North American swine flu, had spread to all 50 states by mid-June.

The World Health Organization declared a pandemic on June 11, 2009.

In Oregon, as of Sept. 4, 2009, there have been 113 hospitalizations of people with confirmed pandemic H1N1 among residents of 11 counties, and 12 deaths among residents

PANDEMIC H1N1 INFLUENZA ACTIVITY has persisted through the summer in Oregon and throughout much of the US. Some states with an early start to the school year have experienced an upswing in cases, and the Oregon Public Health Division expects increases

in pandemic H1N1 activity in the coming months. Pandemic H1N1, coupled with the likely return of more familiar influenza strains, makes preparation for the upcoming flu season especially important.

This article reviews the emerging epidemiology of pandemic H1N1, and offers guidance about testing, treatment, infection control, and prevention of influenza this fall and winter.

PANDEMIC


Need to Know

Fall 2009 • 15

in seven counties. The severity of illness continues to be similar to that seen with seasonal influenza, with the rate of hospitalization among confirmed cases in Oregon measuring in the 10%–15% range.

Compared with seasonal strains, the pandemic virus has been more likely to cause illness among school-age children and less likely to affect persons 65 years of age and older.

Vaccinate!Immunization is the most effective means of minimizing illness and death from influenza. This year we’ll have two vaccines—one for the usual “seasonal” strains, and one for pandemic H1N1. Persons nine years of age and older need a single dose of seasonal vaccine, but for immunity

to the pandemic strain, two doses, spaced three weeks apart, may be required. This information is subject to change.

Health care workers attract patients with influenza and, consequently, are

high priority for both pandemic and seasonal vaccines.

“If you want to stay healthy and in business throughout the season, get yourself vaccinated, and offer the same at no cost to your staff, as soon as the vaccine is available,” says Mel Kohn, MD, MPH, State Public Health Director. “Stay informed about the availability of vaccine and what’s going on in your community by working closely with your local public health officials.”

Vaccine against seasonal influenza is currently available. Clinicians are urged to start using it as soon as possible (there is no evidence that immunity in early vaccines will wane before the end of flu season) and to keep immunizing those who haven’t received it as long as influenza is circulating. The groups

recommended to receive seasonal flu vaccine are the same as for last year.

As of mid-September, the CDC expects 45 million doses of pandemic H1N1 vaccine to be available by mid-October, with an additional 20 million doses becoming available each week thereafter. Priority groups for this vaccine are different than for seasonal flu, and include:

9 Pregnant women

9 Household contacts/caregivers for children 6 months of age and younger

9 Health care and emergency medical services personnel

9 All persons six months to 24 years of age

9 Persons aged 25–64 years with health conditions that put them at higher risk of complications. These include chronic pulmonary (including asthma),

cardiovascular, renal, hepatic, hematological, or metabolic disorders (including diabetes); immunosuppression (including that caused by medications or HIV); and conditions (e.g., cognitive dysfunction, spinal cord injuries, seizures, or neuromuscular disorders) that affect respiratory function or handling of respiratory secretions and increase the risk for aspiration.

Respiratory HygieneStress to both staff and patients the importance of hand hygiene and cough etiquette in stemming the spread of respiratory viruses. Make surgical masks available to patients with influenza-like illness (have pediatric sizes available if appropriate), and provide hand hygiene products, facial tissues and receptacles for their disposal in waiting and exam rooms.


Sick LeaveUrge patients with influenza to stay home from work or school until at least 24 hours after they no longer have a fever of 100° F or higher.

Modify sick-leave policies as needed to ensure that members of your staff can stay home should they become ill. Staff members who become sick while at work should withdraw from patient care and notify their supervisor.

Because they work with people who have chronic illnesses, the bar is higher for health care workers—if they have confirmed or suspected influenza, they should abstain from work for

seven days or until asymptomatic for 24 hours, whichever is longer. This guidance may change. For the most up-to-date information on work exclusion for health care workers ill with pandemic H1N1, see www.cdc.gov/h1n1flu/guidance/exclusion.htm.

Triage of PatientsHelp patients with influenza-like illness to decide whether and when to come in for medical evaluation.

Consider using your phone system to inform callers about when to seek medical care at your facility, when to seek emergency care, and where to get information about how best to care for someone with influenza at home

(see “Taking Care of a Sick Person in Your Home” at www.cdc.gov/h1n1flu/guidance_homecare.htm).

Infection ControlHealth care workers who come in close contact with patients who have con-firmed or suspected influenza should wear a gown, gloves and a surgical mask. Eye protection is recommended if any potential splash hazard is anticipated. In the setting of aerosol-generating procedures (nebulizer use, intubation, suctioning, or bronchoscopy), an N-95 respirator should be used instead of a surgical mask.

These recommendations represent the minimum level of infection control precautions—increased levels of infection control may be employed as indicated by a specific patient or situation.

The CDC’s current guidance is more conservative, with recommendations for N-95 respirators for all health care workers who have close contact with patients with suspected or confirmed pandemic H1N1 influenza. At press time, CDC was re-evaluating its guidance in light of a recent Institute of Medicine report and other input, and is expected to issue updated guidance in early October.

TestingThe pandemic strain can, unfortunately, elude detection by rapid flu tests—depending on the assay, the sensitivity of such tests can be as low as 10%. Therefore, a negative rapid test does not reliably rule out influenza, and decisions regarding treatment, exclusion from work, school, etc., should be based on clinical judgment.

Pandemic H1N1 has already spread throughout Oregon, and public health surveillance efforts will focus on severe disease, based on hospitalizations and deaths. The Oregon State Public

Health Laboratory will test, free-of-charge, specimens from hospitalized patients. We ask that specimens from all patients hospitalized with suspected influenza be collected as soon as possible after admission. OSPHL will no longer perform influenza testing on specimens from outpatients, except those from facilities working with us on special projects.

Antiviral TherapyAntiviral therapy is recommended for persons with suspected or confirmed pandemic H1N1 influenza who are at increased risk of complications from influenza, or who have symptoms severe enough to require hospitalization.

People considered to be at high risk include pregnant women, infants and children up to five years of age; persons aged 25–64 years with certain chronic medical or immunosuppressive conditions (see above), and persons younger than 19 years of age who are receiving long-term aspirin therapy.

The CDC recently released revised guidance that encourages clinicians to “lean forward” in considering antiviral therapy for their high-risk patients to help ensure that those who may need antiviral medications receive them as quickly as possible (within 48 hours of illness onset).

Treatment generally should not wait for laboratory confirmation of influenza because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza.

Steps to take to reduce delays in treatment:

9 Inform persons at higher risk for influenza complications about the signs and symptoms of influenza and the need for early treatment after onset of symptoms. The symptoms of pandemic H1N1

Find up-to-date H1N1 information and guidance at:

www.flu.oregon.gov

Find slides from Dr. Kohn’s presentation at the OMA Fall Forum at:

www.theoma.org/h1n1flu

What Physicians

Need to Know

Fall 2009 • 17

and seasonal flu infection include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people may also have vomiting and diarrhea. People may be infected with the flu, including pandemic H1N1, and have respiratory symptoms without documented fever.

9 Ensure rapid access to telephone consultation and clinical evaluation for these patients as well as patients who report severe illness.

9 Consider empiric treatment of patients at higher risk for influenza complications based on telephone contact if hospitalization is not indicated and if this will substantially reduce delay before treatment is initiated.

9 In selected circumstances, providers might also choose to provide selected patients at higher risk for influenza-related complications (for example, patients with neuromuscular disease) with prescriptions that can be filled at the onset of symptoms after telephone consultation with the provider.

Antiviral chemoprophylaxis generally should be reserved for persons at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza. As an alternative to chemoprophylaxis, clinicians may also choose to counsel persons at higher risk who may have been exposed to influenza to immediately contact a health care provider for evaluation and possible early treatment if clinical signs or symptoms develop.

Persons with suspected pandemic H1N1 influenza or seasonal influenza who present with an uncomplicated febrile illness typically do not require treatment unless they are at higher risk for influenza-related complications.

What are the signs and symptoms of pandemic H1N1 flu?

Pandemic H1N1 flu symptoms are similar to the symptoms of seasonal flu and include fever, cough, sore throat, body aches, runny or stuffy nose, headache, nausea, chills and fatigue. Some people have reported diarrhea and vomiting due to pandemic H1N1 flu.

Is pandemic H1N1 influenza worse than the usual influenza?

Pandemic H1N1 has been similar in severity to usual strains of influenza. However, since few people have immunity to the new virus, more people may get sick and this may lead to an increased number of hospitalizations and deaths.

How long can an infected person spread this virus to others?

People infected with either pandemic H1N1 or seasonal flu shed virus and may be able to infect others from one day before getting sick until five to seven days after. If you get sick, remember to stay home—and keep sick children home—until free from fever for 24 hours.

What if I’m ill and don’t have a health care provider or insurance?

If you have a severe illness such as sustained high fever or difficulty breathing, or you believe that you require immediate medical attention, call 911 or go to your nearest emergency department. If you feel you need to see a doctor regarding your flu symptoms, but don’t have health insurance or a regular doctor, call 1-800-SAFENET (723-3638) for referral to a nearby, low-cost clinic.

How do I care for someone who is ill with pandemic H1N1 flu?

The CDC recommends these guidelines:

9 First, check with the health care provider about any special care the person may need for certain health conditions such as pregnancy, diabetes, heart disease, asthma or emphysema—and to determine if the sick person should take antiviral medication.

9 Treat the flu sufferer with over-the-counter pain and fever relievers such as acetaminophen or ibuprofen, but NEVER give aspirin to children or teenagers. This can cause a serious illness called Reye’s Syndrome.

9 Do not give children younger than four years of age over-the-counter cold medications without first checking with their health care provider.

9 Avoid being face-to-face with the sick person and try to provide good ventilation.

9 Wash your hands after touching the sick person and keep surfaces clean.

9 Keep the sick person at home but away from others in the house as much as possible, as least until fever is absent for 24 hours.

9 Make sure the sick person drinks plenty of liquids.

Pandemic H1N1 Frequently Asked Questions

Oregon Public Health Division—8-25-09


Where Can Health Care Providers Go for More H1N1 Information?

Pandemic H1N1 influenza laboratory testing and the use of antiviral medication:

www.oregon.gov/DHS/ph/acd/flu/provider-testing.pdf

Oregon Public Health Division guidance for infection control for patients with pandemic H1N1 influenza:

www.flu.oregon.gov

CDC guidance on antiviral recommendations:

www.cdc.gov/h1n1flu/recommendations.htm

CDC guidance on pandemic H1N1 specimen collection:

www.cdc.gov/h1n1flu/specimencollection.htm

Pandemic H1N1 Frequently Asked Questions

What about the use of antiviral drugs to treat pandemic H1N1?

Antiviral drugs, such as Tamiflu® and Relenza®, are prescription medicines that fight against the flu by preventing flu viruses from reproducing in your body. If you get sick, taking antiviral drugs within 48 hours of first developing symptoms can lessen the severity of the illness. Antiviral drugs may also prevent serious flu complications. It’s important to remember that antivirals are not a “silver bullet.” It is impractical to take antivirals to prevent getting the flu because you’d have to take them constantly and they are expensive. Also, the misuse of antivirals can lead to the development of flu viruses that can’t be treated.

Does Oregon have antiviral medicines?

The State of Oregon has purchased antiviral medicine and Federal stockpiles are available if necessary. This fall, antivirals may be prioritized for individuals with severe illness or those at higher risk for flu complications.

Who should get a pandemic H1N1 flu shot?

According to the CDC, the pandemic H1N1 vaccine will first be available to the following five priority groups:

9 Children and young adults from 6 months to 24 years

9 Pregnant women

9 Health care workers and emergency medical responders

9 People caring for infants under 6 months of age

9 People aged 25–64 with underlying medical conditions (such as asthma, immune-deficiencies, etc.).

How should I prepare for a major flu outbreak in my community?

There are many things you can do right now to prepare for a major pandemic H1N1 outbreak in

your community:

Plan. Make a work plan for ensuring essential duties can be completed if large numbers of employees are absent over many months. Make household and emergency plans such as deciding who will care for children if schools close and how you will care for family members with disabilities if social services are limited.

Be prepared to get by for at least a week on what you have at home—stores may close or have limited supplies.

Keep these items in your home:

9 Enough food and water per person to last a week or more.

9 Medications, at least a week’s supply of the medicines you take regularly.

9 Items to relieve flu symptoms such as cold packs, blankets, humidifiers, and fever and pain reducers like acetaminophen and ibuprofen. Never give aspirin to children or teens; it can cause a serious disease called Reye’s Syndrome.

9 Personal items. Store at least a week’s supply of soap, shampoo, toothpaste, toilet paper and cleaning products.

9 Activities for you and your children including books, crafts, board games and art supplies.

9 Cash. Banks may not always be open.

9 Pet supplies: food, water and litter.

9 Cell phone or landline phone with a cord.

9 Large trash bags—garbage service may be disrupted.

Protect your health by getting a seasonal flu vaccine, the H1N1 vaccine when it becomes available, and not smoking.

Are there guidelines for child care providers?

Guidance for child care providers is available at the Oregon State Health Division H1N1 flu Web site at www.flu.oregon.gov. Additional information is also available at www.cdc.gov/h1n1flu/schools.

What Physicians

Need to Know

Fall 2009 • 21

Health Information TechnologyMichigan Practice Profits from HIT

Contributed by AMA Staff

Advocacy in Focus

DECREASING YOUR MONTHLY CHART PULLS can save your practice thousands of dollars.

If that seems hard to believe, then just ask Michael Zaroukian, MD, an East Lansing, Mich., internist and early adopter of Health Information Technology.

After helping the Michigan State University Internal Medicine Clinic implement an electronic health records system in 2002, Dr. Zaroukian, professor of medicine and chief medical information officer at MSU, decreased his own practice’s chart pulls by 88 percent and 99 percent after 12 and 24 months, respectively. This reduction, Dr. Zaroukian said, has greatly benefited his practice financially and is something he couldn’t have possibly done without the help of an EHR.

Successfully implementing an EHR and other forms of health IT systems can directly assist with the administrative efficiency and workflow of one’s practice, as was the case with Dr. Zaroukian’s. His practice also saw staff productivity improve and virtually eliminated transcription and paper chart costs.

“Early on in my training it became clear to me that it is difficult to impossible for physicians to consistently provide high-quality care in our information-intensive clinical environment using paper charts and books on shelves,” said Dr. Zaroukian. “I researched the entire process in order to convince MSU that the time required to implement

an EHR and the benefits of doing so were worth all the risks.”

And today, he has shown that they are. From streamlining and automating processes and administrative functions—such as appointment scheduling, viewing of insurance and billing history, and managing the claims and revenue cycle—to better intra-office communication, ordering labs for treatment and pick up of prescriptions, the practice’s pace of information workflow has improved dramatically.

After less than 17 months of use, the MSU Internal Medicine Clinic has recouped its entire EHR implementation costs. In addition, the clinic has saved more than $85,000 in medical record chart pull charges, more than $75,000 in transcription savings and more than $120,000 on staff from EHR implementation.

But not all physicians recoup EHR costs that quickly. In fact, many view cost as a huge barrier to implementing a health IT system. And that’s just one of the many reasons that Dr. Zaroukian said has stopped his colleagues from following his lead. Others pertain to questions surrounding interoperability, IT support, staff training and political underpinnings.

Dr. Zaroukian, a physician leader of MSU’s enterprise-wide EHR initiative—now in its ninth year—said the decision to implement an EHR system was really for one reason: his patients. “The best alternative I could see to

deliver quality care to my patients on a consistent basis was to adopt health IT and optimize it as a tool to improve care,” he said.

Another form of health IT, ePrescribing, can be a good starting point for many physicians, and the AMA’s online ePrescribing learning center can help get you there. Visit www.ama-assn.org/go/eprescribing to access the learning center, which is open to all physicians.

The AMA recently unveiled enhanced tools for ePrescribing on the site, including a system finder that selects three systems for a user based on their responses to a brief questionnaire; side-by-side comparisons of up to three ePrescribing vendors at one time; the ability to read vendor feedback and ratings from other users and provide your own vendor feedback; and automated contact-a-vendor capability for when a decision is reached.

And for loads of technology planning resources to help decide what’s right for your practice, visit www.ama-assn.org/go/hit to learn more about health IT, planning your transition, the AMA’s activities on this issue and much more. The AMA will continue to develop new resources and solutions for physicians to simplify the health IT decision-making and implementation processes, so bookmark both of these web pages and check back often.

To join the AMA or renew your membership, visit www.ama-assn.org or call AMA Member Relations at (800) 262-3211.

Fall 2009 • 23

Career TransitionsA Life-Long TripBy Gary Schaub

In the Office

A MEDICAL PRACTICE CAREER will involve several transitions over time. How you handle those

transitions will determine the personal and financial success of your life as a physician. There are no GPS coordinates that you can follow as a road map to long-term success. But, if you know where you are and where you want to go in your career, then life’s unexpected detours will not keep you from your destination.

Medical School Training to Real-world MedicineOptions at this stage include working as an employee or associate in small to large-group private practice settings, hospital employment, government clinic employment, Armed Forces, and academic teaching and/or research. At this stage, very few physicians start their own practices, become an equity partner in a practice, or purchase a solo practice.

The first step in this transition is to determine if this decision will lead to a lasting relationship with your employer and further your career goals. In one study, the key element of physician turnover was “poor cultural fit with the practice.” Thus, spend the time to make sure you have found the right practice situation for yourself. Once this is done, the next step is to sign an employment agreement. Be prepared, though, because this contract may be a

key factor in shaping your future career direction.

Nail down the basics of the job description, hours, and compensation. Then, focus on how to get out of the job situation if it does not meet your needs. A Noncompetition Clause, or Restrictive Convenant, needs more attention than any other part of the employment agreement. For example, if you think that in the future you would like to go into your own private practice in a community, then do not accept an employment contract that will limit your ability to do this. A restrictive covenant will normally specify a specific geographical area where you will not be able to practice for a certain time period. In this case, you may want to work for someone in a community close by, so that your future practice options will not be curtailed. Who will pay for the malpractice insurance (Tail Coverage) is another issue to address. It can be very expensive when an employment agreement is terminated.

What are other reasons for associateship failures? They usually involve personality, practice management, or compensation problems. Always consult with an attorney or trusted adviser before signing employment agreements.

The Decision to Own a PracticeKey characteristics that determine the outcome of this step include the following:

� Ability to be a good business manager

� Strong leadership skills

� Measure and achieve goals

� People skills

� Use of team members, such as consultants, CPAs, attorneys, and lenders

� Having a balanced life

In my experience, the successful transition to solo private practice or a partnership involves a buy-in timeline. Like a marriage, choosing the wrong partner can be catastrophic. Whether you are an employee or the practice owner/partner, I suggest having a honeymoon phase of six to 24 months so that everyone can get acquainted and determine if the relationship can


be permanent. Before this phase is over, the decision concerning future ownership must be made. Ideally, the cost of the future buy-in will have been determined up front through a comprehensive practice appraisal. Then, a legal sale agreement can seal the deal. Following these steps results in very few surprises that could derail the practice transition.

The Decision to Retire or Leave MedicinePhysicians, however, can have trouble giving up the practice of medicine. It can be all-consuming, leaving little time for personal growth and identity. As the British journalist Malcom Muggeridge stated, “Few men of action have been able to make a graceful exit at the appropriate time.” It is important to remember that attaining the age of 65 does not demand immediate retirement. Actually, age has no bearing on when to retire. That is a personal decision based on many factors other than age. Post retirement success usually involves role realignment, interests, hobbies, volunteerism, and putting something back to society. Financial considerations may be secondary to personal considerations.

Achieving a successful transition to retirement, if you are in private practice, is the result of good planning. Finding the right buyer, coordinating the transition period, determining financial parameters, and achieving success all take time and good advisors.

Ultimately, career success is helped by having a road map to identify, and handle, critical stages in the trip.

Gary Schaub is an appraisal and transition consultant for physicians, and author of the medical economics book, Selling or Buying a Medical Practice.

He can be reached at (503) 223-4357, or by email at [email protected].

Career Transitions — A Life-Long Trip

Fall 2009 • 25

THE 2009 LEGISLATIVE SESSION brought significant improvements to the liability climate for

physicians and other providers who respond and volunteer to provide medical care during disasters or declared public health emergencies. As Oregon prepares for and responds to the ongoing outbreak of H1N1 influenza, these changes are timely and important for physicians and other providers to know and understand.

Physicians and other health care providers often see a surge of patients during a public health emergency. Providing care during such an emergency could expose physicians to potential civil liability under a number of legal theories such as negligence, breach of privacy, intentional or negligent infliction of emotional distress, and misrepresentation. This could have a detrimental impact on physician participation during a public health emergency. The existence of some sort of immunity for medical services rendered during a time of crisis is a crucial piece of any emergency services statute.

House Bill 3021 strengthens the state’s health care infrastructure to prepare for public health emergencies, such as acts of terrorism, natural disaster, or an emerging infectious disease. This legislation, along with other bills, amends the laws relating to emergencies and first responders. Most importantly, the bill designates health care providers, health care facilities,

operators of emergency health care centers, and other volunteers to serve as agents of a public body under the Oregon Tort Claims Act during a declared emergency event.

ORS 401 and HB 3021– During Declared EmergencyOregon has an emergency services and communications statute (ORS 401 et. seq.) that provides for the prevention, mitigation and management of emergencies or disasters that present a threat to the lives and property of citizens of, and visitors to, the State of Oregon. HB 3021 amends ORS 401 to extend civil liability protections during a declared state of emergency or state of public health emergency.

What this Means for PhysiciansBefore a physician can be considered an agent of a public body and receive the liability protections of the OTCA, ORS 401.667 requires licensed physicians to register with the Department of Human Services. DHS maintains a registry of emergency health care providers who are available to provide health care services during an emergency (www.oregon.gov/DHS/ph/serv-or).

The bill passed this year removes the previous prohibition on compensation, allowing a registered physician to receive liability protection regardless of whether he or she is compensated. Furthermore, HB 3021 defines boundaries of what the physician can

do during the emergency. Medical services must be “within the course and scope of the health care provider’s duties” and “pursuant to directions from a public body.”

In addition, Senate Bill 8 permits licensed out-of-state physicians to participate during a declared emergency. Before SB 8, ORS 401.651 limited health care providers to those individuals licensed to administer health care services in Oregon. SB 8 expands the term health care provider to include those individuals licensed or permitted to administer health care services in another state. This means that physicians licensed to practice in another state are extended liability protection under ORS 401.667 during an emergency or crisis situation. In order for this protection to be applicable, the physician must be licensed in another state, registered with DHS to provide health care services in Oregon during an emergency, and there must be a declared emergency or state of public health emergency.

For more information, visit the Oregon DHS Public Health Emergency Preparedness website at www.oregon.gov/DHS/ph/preparedness/han/index.shtml.

What this Means for Hospitals and Health Care FacilitiesMost people look to their local hospitals or primary care clinics for medical treatment during a major

Physician Liability Protectionsduring Disasters or EmergenciesBy Annabel Lucas, JD

In-House Counsel


disease outbreak or pandemic. Hospitals currently have limited statutory protections for complying with the directives of public health authorities or responding to a disaster in general. If the Governor declares a state of emergency or a state of public health emergency as defined earlier, hospitals and health care facilities designated as emergency health care centers will be considered agents of the state. Like individual responders, hospitals and health care facilities must be acting pursuant to directions from a public body and must stay within the course and scope of the duties of the health care facility. HB 3021 also provides that health care facilities can be considered agents of the public body and receive liability coverage without regard to whether they are being compensated.

A CaveatThe liability protection articulated in HB 3021 should not be construed to provide blanket liability protection to all providers in all circumstances. The statute only applies to registered physicians and designated health care facilities providing care when the Governor has declared a state of emergency or proclaimed a state of public health emergency. Some public health directives do not rely on a declaration from the Governor and consequently do not provide liability protection to a physician or health care facility. Two situations where OTCA coverage is not generally available include isolation or quarantine, and protocols regarding allocation and distribution of antitoxins or vaccines without the declaration of an emergency.

Oregon Tort Claims ActRecovery on a claim differs depending on whether the physician or hospital/health care facility is deemed an agent of the state or an agent of a local government. Senate Bill 311 places

tort liability caps on public bodies and Oregon Health Sciences University. The bill increases the tort cap to $1.5 million per claim, with scheduled increases of $100,000 per year up to $2 million by 2014. The cap also increases recovery to $3 million per occurrence, with scheduled increases of $200,000 per year up to $4 million by 2014. The effective date for the state and OHSU is retroactive to the Clarke vs. OHSU decision (Dec. 28, 2007).

For local governments, the cap will be $500,000 per claim, with scheduled increases of $33,000 per year up to $666,000 by 2014. The cap also increases recovery to $1 million per occurrence with scheduled increases of $66,000 per year up to $1.3 million by 2014. The effective date for local governments is July 1, 2009. Property damage claims for state and local governments will be limited to

$100,000 per claim and $500,000 per occurrence.

Good Samaritan StatuteOregon law (ORS 30.800) grants partial immunity to physicians who voluntarily and without expectation of compensation, provide medical assistance to persons who are in need of immediate medical or dental care in a place where emergency medical care is not regularly available. The care must be given under emergency circumstances, and suggests that providing assistance is the only alternative to death or serious physical injury. Partial immunity from liability is limited to negligent care. Partial immunity is not available for gross negligence, recklessness, or intentional conduct involved in providing emergency medical assistance.

Annabel Lucas is the OMA Policy Specialist. She can be reached by email at [email protected].

Liability protections during emergencies


I MAY NEVER LEARN all there is to know about disaster preparedness—that is my first conclusion as I

approach my one-year anniversary of leading the OMA Community Health Committee task force on disaster preparedness. When I assumed leadership, the committee already had a good understanding of the state government plans to respond to a pandemic illness; efforts toward addressing medical malpractice

coverage and volunteerism; emergency state certification for volunteer medical personnel; and medico-legal considerations for alternative standards of care. The conversations were now focused on communication disruptions for physicians during a disaster. For instance, our group considered whether to advise doctors to buy HAM radios or satellite phones. When the state discussed blast faxes to

medical offices for pandemics, we were concerned about power interruptions that precluded all electronic-based communication services.

In March, we visited the Anderson Readiness Center in Salem, home of the parallel emergency response systems for state government and armed forces preparedness, with its deputy director of state affairs, Brigadier General Mike Caldwell, and Salem family physician and disaster preparedness committee lead, Doug Eliason, DO. The Center’s leadership reviewed the activation for response and clean-up after the Winter 2008–09 flood, which included major disruption to regional transportation and services to some parts of the state. That same evening we attended the Marion-Polk County Medical Society’s disaster preparedness summit.

Keynote speaker Lt. General Paul K. Carlton, from Texas A&M University gave a presentation on preparedness, focusing on acts of nature or terrorism. The audience and a panel of local and state experts went through a mock disaster exercise based upon an offshore earthquake in the Mid Willamette Valley. We addressed the expected disruptions to power, transportation, and medical services, and learned about preparations for an exercise planned for April to test state preparedness for a large scale natural disaster.

On My Mind

Making Sense of Disaster Preparedness

By Mark Gilbert, MD

Fall 2009 • 29

I was beginning to feel like OMA’s efforts toward readiness for physical disruption of services were now in line with the planned state preparedness efforts. Then disaster struck, in the form of an unusual flu virus, which was rapidly spreading outside expected flu season, and with atypical patterns of at-risk patients. We were back in pandemic response mode. The earthquake preparedness exercise was tabled indefinitely, while the state activated its Portland readiness center for the spring H1N1 flu outbreak.

Since the spring outbreak of H1N1 flu, OMA staff and I have participated in meetings with Oregon DHS public health department, offering specific issues as they relate to members. The PHD has been learning the concerns and information gaps which will form the front lines of this battle. They have endeavored to inform and educate our physician membership of the challenges they may face this fall, and marshal national resources and funding on behalf of all Oregonians.

Our OMA input has touched on disparate issues such as mandatory vaccination for health care workers; length of mandatory furloughs for exposed health care workers; which standard (CDC or WHO) of personal protective equipment to wear during care of patients with influenza-like illness symptoms; prioritization, distribution and administrative fees for vaccination; as well as encouragement of public health and safety announcements. This last informational “push” will help by informing patients to act as the first filter against making unnecessary medical office visits. Those visits could lead to overfilled waiting rooms, and potentially mix infectious patients with high-risk patient populations.

Many of the information sources share a common theme. They break disaster preparedness into three stages, whether

the event is physical, medical, or mixed in nature.

Begin by (1) informing yourself, your family, your staff and patients about what source of information you are using to make plans.

Then (2) form your plans; post them conspicuously on your website and in your physical office, so you, your staff and your patients have access, and understand what to expect. Drill your office staff and your family on how they will respond, so it is second nature to them. This planning stage includes how to address transportation challenges, communication disruption, and staff responsiveness to flexing office coverage.

Finally, (3) gather and prepare the materials, and arrange their storage, which you and your practice will need to continue services should an event occur. Most experts suggest a minimum

of 72 hours of supplies; others suggest as much as one week, based upon typical response time by state and federal agencies.

We will endeavor to continue to inform, protect and represent the doctors, patients and communities served by OMA as we work through fall flu season, and prepare against other disasters that threaten the health and safety of Oregonians.

Mark Gilbert is an anesthesiologist in Salem, chair of the OMA Community Health Committee, and president of Marion-Polk County Medical Society. He can be reached by email at [email protected].

I was beginning to feel like OMA’s efforts toward readiness for physical disruption of services were now in line with the planned state preparedness efforts. Then disaster struck...


RESIDENTS IN SALEM and surrounding communities have a new resource for reliable

health information, education and support. The new Community Health Education Center, located on the Salem Hospital campus, is focused on connecting patients, families and community members with high quality health information and resources to help them be informed and empowered to take control of their health.

The Community Health Education Center officially opened in October and comprises five areas: the Pierce Resource Center, a community health library named in recognition of the contribution of OMA member Bud Pierce and his wife Selma; the Gehlar Wellness Kitchen, a state-of-the-art cooking classroom; the Gerlinger Support Group Room; the Dr. J.A. King Clinical Staff Library; and the Green Education classrooms. Among the 1,200 donors who supported the Center, Mid-Valley IPA donated $500,000, including matching gifts, in support of the center.

The health education resources, support groups, and classes offered by the Community Health Education Center are focused on both prevention of disease and chronic disease management. The Center also teams up with local public health organizations to offer classes and health resources to the community.

For example, in partnership with the Salem-Keizer School District, the Community Health Education Center will offer a program called “Get Fit Salem” to fifth grade students at 21 area Title 1 schools. Each student in this program will receive a pedometer and journal that will encourage them to not only increase their daily activity but also will teach them how to eat healthier. This 12-week program, sponsored by the Salem Hospital Foundation, kicks off this fall.

The Community Health Education Center has also partnered with the

Taking Control with Health EducationBy Kristin Jordan, RN, MPH

In the Spotlight...

Fall 2009 • 31

Community Health Education Center at Salem Hospital

Farmworker Housing Development Corporation in Salem, Woodburn, and Independence to offer Tomando Control de su Salud, which is a Spanish-language chronic disease management program developed by Stanford University. This workshop gives participants valuable information on: healthy eating; communicating with family, friends, and health professionals; appropriate use of medications; and appropriate exercises for maintaining and improving strength, flexibility, and endurance. A Living Well with Chronic Conditions workshop is also offered. This class is a chronic disease self-management program, which provides participants with chronic conditions the tools for living a healthy life.

Another partnership is with the American Red Cross. Various classes will be offered at the Community Health Education Center including first aid, basic aid training and babysitters training.

The Community Health Education Center is committed to providing individuals with valuable health

resources, both in the Center as well as through outreach services in the community. To learn more about the programs and services offered, as well as the Center’s many community partners, visit www.salemhealth.org/chec or call (866) 977-CHEC (2432).

Kristin Jordan, RN, MPH is a health educator in the Community Health Education Center at Salem Hospital. Kristin may be reached at [email protected].

Medicine in Oregon welcomes contributions from organizations and institutions throughout the

state who want to share news and information with OMA members.

Contact Betsy Boyd-Flynn at [email protected]

for submission guidelines.

Physician OpeningsFAMILY PRACTICEGRANTS PASS, OREGON Seeking 2 BC/BE Family Practice physicians to join 3 physician FP Department; physician-owned, financially strong, multi-specialty group of 26 providers with 60 year history. 4 day work week and 1:8 weekday and weekend call. Obstetrics is optional. First year salary guarantee plus incentive bonus. Moving allowance, partner consideration after first year; located on hospital campus. Many cultural events and recreational activities in this beautiful com-munity and region that serves 85,000. (Not a J-1 Opportunity) Send CV and letter of interest to: Grants Pass Clinic, Attn: Susan Sartain, Human Resources Director, 495 SW Ramsey Ave., Grants Pass, OR 97527 Ph 541-472-5500 Fax 541-472-5671 Email ssartain@ grantspassclinic.com www.grantspassclinic.com

FAMILY PRACTICE PHYSICIAN WANTED, Cle Elum, Washington - Owned by Kittitas Val-ley Community Hospital in Ellensburg, WA, the beautifully renovated lodge-style Cle Elum Medical Center offers a full spectrum of fam-ily medical services for patients of all ages. This is any excellent F/T opportunity for BC or BE physicians to provide comprehensive and personalized care in a wonderful rural setting. Located in the heart of Washington, Cle Elum is just 75 minutes from downtown Seattle for your big city fix and 30 minutes from skiing for outdoor enthusiasts. Cle Elum offers an excellent recreational location and a historical, small town atmosphere with a great sense of community. We offer competitive pay, gener-ous health and retirement benefits and relo-cation assistance! No hospital call due to full Hospitalist program! Send CV to Julie Johnson, [email protected] or fax 509-933-7529

Physician OpeningsFAMILY PRACTICEMULTNOMAH CO. HEALTH DEPARTMENT is seeking a Full Time (.8 FTE) Internal Medi-cine/Family Practice Physician for Corrections Health. The Health Department provides health, mental health and dental care to all detainees in Multnomah County. This position works with other provider staff to provide di-rect clinical care to the adults and juveniles in custody, Health care for this population is com-plex with multi-system health conditions. Cor-rections Health has one mental and two medi-cal health infirmaries for our acutely ill. The adult facilities are staffed 24/7 with Registered Nurses. This physician would join the provider team who provides rotating call after hours. This Physician reports to the Health Depart-ment Medical Director as well as the Correc-tions Health Director. The Health Department is seeking physicians comfortable with caring for the medically indigent, enthused about cross-cultural medicine and oriented toward preventive health. Experience with the public safety system, addicted population, multi-sys-tem health care needs and unstable chronic diseases are desired. Qualified candidates must be board certified or board eligible; this position is not a J-1 visa or HB-1 opportunity. Multnomah County has 2 adult jail facilities and 1 juvenile detention facility totaling 1450 beds. There are diverse clinical and clerical personnel who carry out the evaluation, treatment and operations of a wide range of health problems. Salary Range is $113,327.00 - $158,783.00 annually. Plus a 5% Corrections Premium and a 5% Medical Director Premium Candidate must pass the Sheriff’s Office security clearance. To apply, please visit: www.multcojobs.org. Job#9490-08

Physician OpeningsFAMILY PRACTICEPROVIDER POSITION OPEN: We are a growing, progressive family practice located in the Portland metropolitan area. Currently, we’d like to welcome a new provider to our long established medical team comprised of both M.D and D.O physicians. We are particu-larly interested in a physician who is able to form wellness partnerships with our patients and who is comfortable with patient shared decision making. We are now preparing to de-velop our practice as a Wellness Center with those ancillary services most suited to our community and patient population. For this reason, candidates must consider the clinic’s overall wellbeing before their own and be able to collaborate with other providers together with team management. We would like to share this dynamic time in our growth with the right professional. Candidates must have an active Oregon license, DEA certification and be Board Certified in Family Medicine or Pediatrics. Those with Pediatric certification should be willing to also treat adults initially with an objective of pediatrics eventually being 30-50% of their practice. Physicians applying should be able to work 3 – 4 days per week (24-32 patients contact hours) eventually seeing 24 – 28 patients per 8 hour day. Our start date would be negotiable using February 1st, 2010 as the latest start date possible. We provide an extremely attractive work setting, compensation and generous benefits. Please respond by sending your CV and a cover letter that best describes your professional philoso-phy and personal profile to [email protected]. We look forward to hearing from you.

GENERAL SURGERYGRANTS PASS, OREGON Seeking a second BC/BE General Surgeon (with or without sub-specialty training) with a 1:8 call and four day work week, to join our physician-owned, fi-nancially strong, multi-specialty group of 26 providers with a 60 year history. First year salary guarantee plus incentive bonus; Mov-ing allowance; Partner consideration after first year; Located next to hospital. Many cultural events and recreational activities in this beau-tiful community and region that serves 85,000. Send CV and letter of interest to: Grants Pass Clinic, Attn: Susan Sartain, Human Resources Director, 495 SW Ramsey Ave., Grants Pass, OR 97527 Ph 541-472-5500 Fax 541-472-5671 Email [email protected] or visit us at www.grantspassclinic.com.

Physician OpeningsINTERNAL MEDICINEGRANTS PASS, OREGON Seeking 2 BC/BE Internists to join 12 physician IM depart-ment. 4-day work week and a 1:6 weekend call. Physician owned, financially strong, multi-specialty group of 26 providers with a 60 year history. First year salary guarantee plus incentive bonus; partner eligible after first year; newly constructed clinic located across from hospital. Many cultural events and recreational activities in this beautiful community and region that serves 85,000. (Not a J-1 Opportunity) Send CV and let-ter of interest to: Grants Pass Clinic, Attn: Susan Sartain, Human Resources Director, 495 SW Ramsey Ave., Grants Pass, OR 97527 Ph 541-472-5500 Fax 541-472-5671 Email [email protected] or visit us at www.grantspassclinic.com.

OMA Classifieds VIEW THESE CLASSIFIEDS ONLINE or PURCHASE AN AD at: www.OMAclassifieds.org

Physician OpeningsINTERNAL MEDICINETHE ISLAND’S CALLING. (Campbell River, British Columbia, Canada) Join us as a General Internal Medicine consultant, with room for a sub-specialty practice. Consider practicing in the beautiful oceanfront city of Campbell River (population 40,000) on the eastern shore of Vancouver Island. Enjoy year-round access to world-class golf courses, or visit Mt. Washing-ton Resort for spectacular winter skiing and summer mountain biking. The surrounding wa-ters of Discovery Passage and numerous lakes and rivers offer an idyllic setting for outdoor and fishing enthusiasts. In Campbell River, you will be eligible to read echocardiograms/stress echocardiograms/holter monitors/spirometry/ECGs as well as do stress tests, bronchosco-py and endoscopy. Campbell River & District Hospital – 59 beds, with an on-site CT and 5 ICU beds (managed by Internal Medicine) – provides services to a referral population of 55,000. Enjoy a collegial and academic In-ternal Medicine work group with opportunities for teaching and research. There are future plans for a new hospital, including all of the currently provided health care services plus an additional 20 beds. General Internists with 4 years’ post-graduate training in the United States who hold ABIM in their specialty may not need to sit Canadian examinations. For further information, contact Dr. Jennifer Sun-derwood, Site Chief, Medicine, at [email protected]. To apply, forward a CV and the names of three references to: Brenda Warren, Leader, Physician Recruitment, email: [email protected] or fax: 250-716-7747. Discover Vancouver Island — with unlimited possibilities for your career, family and future.

Physician OpeningsINTERNAL MEDICINEWELL ESTABLISHED, HOSPITAL-OWNED Internal Medical practice seeking Internists to Escape to Washington State’s best kept secret…Kittitas Valley Community Hospital in Ellensburg, Washington is located in a beauti-ful university town on the sunny side of the Cascade Range, with proximity to Washing-ton’s wine country, outstanding schools, and a quaint historic downtown district. Enjoy a 4 day work week! No hospital call and no week-end call due to full Hospitalist program! Com-petitive & Negotiable salary, relocation and attractive benefit pkg! Send CV to Julie John-son, [email protected]; fax 509-933-7529.

Physician OpeningsPEDIATRICSPEDIATRIC URGENT CARE clinic open No-vember 1, 2009, seeks Pediatricians for walk-in clinic. M-F, 7–10 pm and weekends/holidays 1–10 pm. Excellent compensation. Clinic one mile west of St Vincent Hospital 11790 SW Barnes Rd #140, Portland, OR 97225 Contact: [email protected] or 503-643-2100.

PRIMARY CARESIX INDEPENDENT INTERNISTS are seek-ing a seventh independent associate, or other primary care associate, for full time practice of medicine at the Olson Memorial Clinic on Boones Ferry Rd. in Lake Oswego. The clinic’s long history and its current members can be viewed at www.olsonclinic.com. For further in-formation call Riccardo R. Foggia, M.D.(ret). Home 503-638-0926; Cell 503-781-4043

Office SpaceINTERNAL MEDICINE – PORTLAND, RIV-ERPLACE; share reasonable expenses, good location, fully equipped, patient parking. Jo-seph A. Parent, MD; Phone 503-241-2245; Fax 503-241-1977

3,600 SF. IN MILWAUKIE – Six exam rooms, X-ray room, and more; signage and parking. $6,000 monthly, MG. Contact Marcele at KLM, 503-201-0833

Volunteer OpportunitiesCHILDREN’S COMMUNITY CLINICS: [email protected]

COALITION OF COMMUNITY HEALTH CLINICS—MULTNOMAH COUNTY: www.coalitionclinics.org

ESSENTIAL HEALTH CLINIC— WASHINGTON COUNTY: www.essentialhealthclinic.org

YAKIMA VALLEY FARM WORKERS CLINICS: www.yvfwc.com

HERMISTON COMMUNITY HEALTH CLINIC: www.yvfwc.com/hermiston.html

MEDICAL TEAMS INTERNATIONAL: www.medicalteams.org

VOLUNTEERS IN MEDICINE CLINIC OF THE CASCADES—DESCHUTES COUNTY: www.vim-cascades.org

OREGON AHEC “IN-A-BOX” PROGRAM: Connecting Students to Current Science Research and Local Health Care Professionals: www.healthyoregon.com/teachers/inabox_announcemnet.php

OMA ClassifiedsVIEW THESE CLASSIFIEDS ONLINE or PURCHASE AN AD at: www.OMAclassifieds.org

11740 SW 68th PkwyPortland, OR 97223Address Service Requested

Volume 2, Number 4 • Fall 2009MEDICINE

in Oregon

Documents

PANDEMIC H1N1 Influenza - Oregon Medical Association