REFERENCE COMMITTEE E

(1)

Item No. Resolution(s)/Report(s) Page No.

1. 501-15: PHYSICIAN ASSISTED SUICIDE 1 502-15: PHYSICIAN ASSISTED SUICIDE 1 2. 503-15: DISABLED PARKING PLACARD ABUSE 2 3. 504-15: DISABLED PARKING PLACARD ABUSE 3

4. 505-15: CURES DATABASE 3

5. 506-15: CURES DATABASE ACCESS 4

6. 507-15: CURES DATABASE ACCESS BY LAW ENFORCEMENT 4 7. 508-15: EHR INTERFACE CONNECTIVITY AND

INTEROPERABILITY 5

8. 509-15: REVIEW AND RESPOND TO THE PERILS OF EHR 5 9. 510-15: IMPROVED MEDICAL RESPONSE TO CHILDHOOD

BULLYING 6

10. 511-15: TREATMENT OF MINORS IN PSYCHIATRIC FACILITIES 7 11. 512-15: OPPOSING PROLONGED SOLITARY CONFINEMENT 7 12. 513-15: DISCIPLINE FOR PHYSICIANS MAKING FALSE CLAIMS

USING MASS MEDIA 8

13. 514-15: HOSPITAL JOINT VENTURES WITH CORPORATE

PHYSICIAN PRACTICE MANAGEMENT GROUPS 9 14. 515-15: PRESCRIBING USING TELEMEDICINE 10

(2)

October 16 - 18, 2015

Report of Reference Committee E – Quality, Ethics & Medical Practice Issues Presented by David Bazzo, MD, FAAFP, Chair

NOTE: This report and the recommendations of the Reference Committee do not represent the official actions or policy of the California Medical Association. These recommendations are presented for consideration by the CMA House of Delegates, which then promulgates the policies of the CMA.

Members of the CMA House of Delegates: 1

2

The reports and resolutions referred to Reference Committee E have been considered by our 3

Committee, which met at 3:30 PM via UberConference and Telephone Conference in 4

California on October 4, 2015. Members of the Committee present include: David Bazzo, 5

MD, FAAFP, Chair; Ameena Ahmed, MD; Stephanie Booth, MD; Michael Cedars, MD; 6

Robert Edelman, MD; and James Washington, MD. 7

8

1. Resolution 501-15: PHYSICIAN ASSISTED SUICIDE 9

Author: Richard N. Gray, Jr., MD 10

RESOLVED: That CMA’s policy regarding physician involvement in patients’ desire to 11

end their lives be limited to certification of their having a terminal illness 12

and certification of their capacity to make medical decisions. 13

14

Resolution 502-15: PHYSICIAN ASSISTED SUICIDE 15

Author: William S. Andereck, MD, FACP 16

RESOLVED: That physician participation in willingly assisting or participating in a 17

patient’s death, beyond ascertaining diagnosis, prognosis, and mental 18

capacity, is fundamentally incompatible with the physician’s role as 19

healer; and be it further 20

RESOLVED: That CMA will continue to oppose efforts to involve physicians in 21

willfully ending life; and be it further 22

RESOLVED: That CMA will remain neutral on end of life options for competent, 23

terminally ill patients that do not involve the participation of physicians. 24

25

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

26

APPROVAL OF THE FOLLOWING SUBSTITUTE 27

RESOLUTION (FOR RESOLUTIONS #501-15 AND 28

#502-15) AND ASKS FOR A "YES" VOTE ON IT. 29

(3)

decision to participate or refuse to participate in physician

aid-in-2

dying.

3 4

Reason(s) for Recommendation: 5

A. Current CMA policy is neutral on physician aid-in-dying (PAD). Given the multiple 6

views and perspectives expressed by CMA member physicians as evidenced by (1) 7

CMA member survey; (2) the Council on Ethical Affairs report; (3) Council of 8

Legislation report; (4) comments from CMA members and delegates of CMA's House 9

of Delegates in response to the CMA Speaker's solicitation of input on PAD and SB 10

128; and (5) the Board of Trustees' action on the PAD policy and legislation, the 11

current position should be maintained. 12

B. CMA policy does not include liability protections for physicians who elect to 13

participate or refuse to participate in physician aid-in-dying. This recommendation 14

clarifies CMA’s intent to protect physician members regardless of their level of 15

participation. 16

17

2. Resolution 503-15: DISABLED PARKING PLACARD ABUSE 18

Author: Robert Bitonte, MD 19

RESOLVED: That CMA support legislation increasing penalties for disabled parking 20

placard violations; and be it further 21

RESOLVED: That CMA support legislation increasing the enforcement of disabled 22

parking placard codes. 23

24

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

25

APPROVAL OF RESOLUTION #503-15 AS 26

AMENDED AND ASKS FOR A "YES" VOTE ON IT. 27

THE RESOLVED PORTION IS AMENDED TO 28

30

RESOLVED: That CMA support increasing penalties for disabled parking

31

placard violations; and be it further

32

RESOLVED: That CMA urge the Department of Motor Vehicles (DMV) and

33

law enforcement to increase the enforcement of disabled parking

34

placard codes.

35 36

A. Increased penalties and enforcement of disability placard violations will act as a 38

deterrent to disability placard abuse. 39

B. Reducing abuse and misuse of disabled parking placards would increase access to 40

designated parking spaces to disabled individuals with a legitimate need for the 41

accommodation. 42

(4)

3. Resolution 504-15: DISABLED PARKING PLACARD ABUSE 2

Authors: Janet Lord, MD, Jeffrey Young, MD 3

RESOLVED: That the criteria for a disabled parking placard (and the relevant form) be 4

revised to include purely functional criteria, i.e. limitation of independent 5

ambulation to less than one city block or 100 yards, regardless of a 6

medical practitioner’s signature; and be it further 7

RESOLVED: That this matter be referred for national action. 8

9

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

10

DISAPPROVAL OF RESOLUTION #504-15 AND 11

ASKS FOR A "NO" VOTE ON IT. 12

13

A. Amending the criteria for disability certification to include purely functional criteria 15

removes physician discretion in certifying a disability that necessitates a disabled 16

parking placard. 17

B. Restrictive criteria to obtain a disabled parking placard could prevent patients with 18

legitimate needs that may not fall under the purely functional criteria from obtaining a 19

placard. 20

21

4. Resolution 505-15: CURES DATABASE 22

Author: Humboldt-Del Norte County Medical Society 23

RESOLVED: That CMA work with the Department of Justice and the CURES 24

Database to allow physicians to access reports to identify all medications 25

that have been ordered under their DEA number. 26

27

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

28

33

RESOLVED: That CMA work with the California Department of Justice to

34

allow physicians to access and review controlled substance

35

prescribing history recorded under their own DEA number in the

36

CURES Database.

37 38

A. Physicians currently do not have access to their own prescriber activity reports in 40

CURES. 41

(5)

allow physicians to evaluate their own prescribing patterns, identify any fraudulent use 2

of their DEA number and provide an opportunity to correct inaccurate information in 3

CURES. 4

C. The substitute makes changes to reflect scope of information maintained in CURES. 5

6

5. Resolution 506-15: CURES DATABASE ACCESS 7

Author: Roneet Lev, MD 8

RESOLVED: That CMA support legislation that would allow CURES access to a 9

physician medical director of health plans, methadone clinics, and 10

medical organizations that are involved in paying and dispensing 11

prescriptions for the purpose of promoting safe prescribing, preventing 12

doctor shopping, and informing prescribers when a patient is obtaining 13

medications that can pose a danger. 14

15

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

16

19

A. The law already allows physician medical directors of health plans, methadone clinics 21

and medical organizations to access CURES to provide care to a patient. 22

B. Allowing access to CURES for any other purpose other than providing care to a 23

patient raises privacy and confidentiality concerns. 24

25

6. Resolution 507-15: CURES DATABASE ACCESS BY LAW ENFORCEMENT 26

Author: Roneet Lev, MD 27

RESOLVED: That CMA support the ability for the California DOJ to accept 28

administrative subpoenas and not require the criminal search warrant or 29

court order for the purpose of running a CURES report on patients who 30

may be doctoring shopping. 31

32

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

33

36

A. Patient prescribing data in CURES contains sensitive medical information that may 38

reveal a patient’s underlying medical conditions. 39

B. Allowing law enforcement to access patient data in CURES without a warrant or court 40

order raises privacy and confidentiality concerns, including potential constitutional 41

issues related to warrantless search and seizure. 42

(6)

7. Resolution 508-15: EHR INTERFACE CONNECTIVITY AND INTEROPERABILITY 2

Author: Christopher Lundquist, MD 3

RESOLVED: That CMA support the concept and critical need for regional and state 4

programs and exchanges that provide secure and affordable electronic 5

health record (EHR) interfaces for sharing vital medical information 6

between health care providers and health care entities. 7

8

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

9

APPROVAL OF THE FOLLOWING SUBSTITUTE 10

RESOLUTION (FOR RESOLUTION #508-15) AND 11

ASKS FOR A "YES" VOTE ON IT. 12

13

RESOLVED: That CMA support local and state programs that enable secure

14

and affordable electronic health record interfaces for the

15

exchange of health information between health care providers.

16 17

A. EHR systems do not necessarily interface with each other and are costly to implement. 19

B. Increased interoperability of different EHR systems facilitates efficient, timely and 20

coordinated patient care amongst health care providers. 21

C. Existing policy already addresses supporting efforts to improve the exchange of 22

information in EHRs between health providers. 23

24

8. Resolution 509-15: REVIEW AND RESPOND TO THE PERILS OF EHR 25

Author: Michael W. Fitzgibbons, MD 26

RESOLVED: That the government suspend requirements for implementation of EHRs 27

and ICD-10 (which will slow physician productivity) until studies have 28

been completed that assess the reduced access to care, the alteration in the 29

physician-patient relationship and the reduction in personal interaction 30

between physician and patient; and be it further 31

RESOLVED: That CMA request a study be performed by the appropriate agency to 32

determine the impact of implementation of EHR on physician 33

productivity. 34

35

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

36

(7)

agency to determine the impact of implementation of electronic

2

health records on the patient-physician relationship and

3

physician productivity.

4 5

A. Considering the high number of incentive payments that have been awarded to 7

physicians, many may not be willing to abandon the incentive program in its entirety. 8

B. After many delays, ICD-10 took effect October 1, 2015. 9

C. In 2013 RAND/AMA reported on physician perception of the quality of care and use 10

of EHRs, finding that EHRs were a source of both promise and frustration, with major 11

concerns about interoperability between systems and the amount of physician time 12

involved in data entry. 13

14

9. Resolution 510-15: IMPROVED MEDICAL RESPONSE TO CHILDHOOD 15

BULLYING 16

Authors: George Fouras, MD, Walker Keenan 17

RESOLVED: That CMA encourage physicians to include peer bullying in any 18

screening for adverse childhood experiences that they provide to 19

California youth, and that quality screening tools and referral resources be 20

made available to clinicians wherever needed and appropriate; and be it 21

further 22

RESOLVED: That CMA calls upon California’s Governor and Legislature to enact a 23

comprehensive program that requires local education agencies to adopt 24

policies that prohibit student discrimination, harassment, intimidation, 25

and bullying and to train school personnel in compliance with such 26

policies. 27

28

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

29

34

RESOLVED: That CMA encourage physicians to consider peer bullying in any

35

screening for adverse childhood experiences that they provide to

36

California youth, and that quality screening tools and referral

37

resources be made available to clinicians wherever needed and

38

appropriate; and be it further

39

RESOLVED: That CMA supports efforts encouraging local education agencies

40

to adopt policies that prohibit student discrimination,

41

harassment, intimidation, and bullying and to train school

42

personnel in compliance with such policies.

(8)

A. The prevention of bullying and other violent or aggressive behavior can be reduced 3

through universal school-based programs, and the physician can help play a role in 4

prevention. 5

B. There are already California laws in place to address bullying, but more could be 6

done. 7

8

10.Resolution 511-15: TREATMENT OF MINORS IN PSYCHIATRIC FACILITIES 9

Author: Jason Bynum, MD 10

RESOLVED: That CMA support the involvement of legal guardians and/or parents in 11

the treatment of minors receiving services in psychiatric treatment 12

programs; and be it further 13

RESOLVED: That the voluntary placement of minors in psychiatric facilities be 14

encouraged; and be it further 15

RESOLVED: That the involuntary placement of minors in psychiatric facilities be used 16

only in emergency circumstances with appropriate legal justification. 17

18

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

19

24

RESOLVED: That CMA support the involvement of legal guardians and/or

25

parents, when appropriate, in the treatment of minors receiving

26

services in psychiatric treatment programs, under a 5150 hold;

27

and be it further

28

RESOLVED: That CMA support the creation of a uniform state standard for

29

who can generate, enforce, release or continue a 5150 hold.

30 31

A. It is not uncommon for legal guardians and/or parents to be told, erroneously, that the 33

treatment of their minor is confidential due to the minor being placed on an 34

involuntary hold. 35

B. California has 58 counties and each county has different requirements as to who can 36

generate, enforce, release or continue a 5150 detention. 37

C. A uniform state standard as to who can generate, enforce, release or continue a 5150 38

hold for minors would ensure the protection of a minor’s due process rights. 39

40

11.Resolution 512-15: OPPOSING PROLONGED SOLITARY CONFINEMENT 41

Authors: Ameena Ahmed, MD, George Fouras, MD, 42

(9)

RESOLVED: The CMA supports limiting the use of long-term solitary confinement to 2

no more than 30 days in adults and 24 hours in minors, due to the 3

profound psychological suffering it causes; and be it further 4

RESOLVED: The CMA support prison physicians and other health care professionals 5

who advocate for their patients to be removed from or not to be housed in 6

Security Housing Units; and be it further 7

9

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

10

15

RESOLVED: The CMA supports limiting the use of long-term solitary

16

confinement of inmates and ending the practice of solitary

17

confinement of minor inmates, due to the profound psychological

18

suffering it causes; and be it further

19

RESOLVED: The CMA support physicians and other health care professionals

20

who advocate for their patients to be removed from or not to be

21

housed in such “Security Housing Units”; and be it further

22

RESOLVED: That this matter be referred for national action.

23

24

A. Solitary confinement has psychological effects on prisoners that can have lifelong 26

consequences. 27

B. Physicians, as health care providers, have an active role in ensuring no harm comes to 28

inmates. 29

C. National trend supports solitary confinement reform. 30

D. Removing references to specific maximum periods provides CMA with more

31

flexibility in advocating this issue. 32

E. Referral for national action is appropriate because the AMA does not have policy on 33

the issue on long-term solitary confinement. 34

35

12.Resolution 513-15: DISCIPLINE FOR PHYSICIANS MAKING FALSE CLAIMS 36

USING MASS MEDIA 37

Author: Jeffrey Young, MD 38

RESOLVED: That CMA require physicians who make public statements about health 39

and science to disclose whether their positions are based on published 40

peer reviewed evidence, standard of care, or personal opinion; and be it 41

further 42

(10)

procedures against doctors who make false public statements using mass 2

media; and be it further 3

5

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

6

11

RESOLVED: That CMA encourage physicians who make public statements

12

about health and science to ensure that their positions are

13

supported by published peer reviewed evidence or

evidence-14

based principles, and include disclosures of any potential conflicts

15

of interest; and be it further

16

RESOLVED: That CMA encourage state licensing boards to impose

17

disciplinary procedures against doctors who recklessly make or

18

disseminate false medical information using mass media.

19 20

A. There are significant potential health repercussions for individuals who do follow non-22

evidence-based medical advice. 23

B. Physician penalties for failing to disclose conflicts of interest may incentivize more 24

transparency from controversial media doctors. 25

C. As amended, resolution broadens support for effective measures from relevant 26

regulatory bodies and alliances that focus on physician professionalism and science-27

based medicine. 28

D. Aligns with existing AMA policy that calls for a report on the professional ethical 29

obligations of physicians in the media, and how unprofessional conduct in the media 30

may be disciplined. 31

32

13.Resolution 514-15: HOSPITAL JOINT VENTURES WITH CORPORATE 33

PHYSICIAN PRACTICE MANAGEMENT GROUPS 34

Author: Tom Sugarman, MD 35

RESOLVED: That CMA immediately make it a high priority to immediately investigate 36

and research the legality of both the joint ventures between corporate 37

physician practice management groups and hospitals and the structure of 38

corporate physician practice groups; and be it further 39

RESOLVED: That CMA will investigate Stark compliance, potential fee splitting, and 40

possible violations of the corporate practice of medicine bar under joint 41

venture agreements between hospitals and corporate physician practice 42

groups; and be it further 43

(11)

Board for appropriate action within California and refer to the AMA for 2

national action. 3

4

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

5

10

RESOLVED: That CMA encourage both investigation and research into the

11

legality of hospital arrangements, including joint ventures, that

12

may have a negative impact on patient care and physician

13

independent judgment; and be it further

14

RESOLVED: That CMA encourage investigation of Stark compliance,

15

potential fee splitting, and possible violations of the corporate

16

practice of medicine bar under hospital arrangements, including

17

joint ventures, that may have a negative impact on patient care

18

and physician independent judgment; and be it further

19

RESOLVED: That CMA make available to CMA members updates on

20

advocacy efforts regarding hospital arrangements, including joint

21

ventures, that may have a negative impact on patient care and

22

physician independent judgment and report this issue to the

23

Board of Trustees for appropriate action.

24

RESOLVED: Refer, if appropriate, to the AMA for national action.

25 26

A. Existing CMA policy already provides for scrutiny of hospital arrangements, including 28

joint venture arrangements. 29

B. CMA currently is engaged in activities that will investigate the legality of hospital 30

joint venture arrangements. 31

C. The amendment updates existing CMA policy to adapt to the current healthcare 32

market. 33

D. In order to provide updates on CMA advocacy efforts on this issue, information can be 34

made widely available to CMA members through CMA Alert, newsletters, and the 35

CMA website. 36

37

14.Resolution 515-15: PRESCRIBING USING TELEMEDICINE 38

Author: Michael Borok, MD 39

RESOLVED: That CMA advocate that the Medical Board of California construct 40

telemedicine regulations that state that a physician cannot prescribe a 41

medication without first establishing a defined physician-patient 42

(12)

performed during a face to face encounter. 2

3

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

4

REAFFIRMATION OF POLICY (BOT 07-24-15:3) IN 5

LIEU OF RESOLUTION #515-15. 6

7

A. California state law requires an appropriate prior examination prior to prescribing 9

medication. 10

B. California and federal law does not require the examination to be in-person and allows 11

for the examination to occur via telehealth, using a two-way, real-time interactive 12

audio and video communication system. 13

C. Recently adopted CMA policy on the Principles of Telemedicine already addresses 14

establishing a physician-patient relationship prior to the use of telemedicine. It states 15

that "[a] physician-patient relationship must be established, through at minimum, a 16

face-to-face examination, if a face-to-face encounter would otherwise be required in 17

the provision of the same service not delivered via telemedicine. The face-to-face 18

encounter could occur in person or virtually through real time audio and video 19

technology." (BOT 07-24-15:3). 20

21

15.Report E-1-15: POLICY SUNSET REVIEW 22

23

RECOMMENDED ACTION: YOUR REFERENCE COMMITTEE RECOMMENDS

24

THAT POLICIES 101a-05, Resolved 1; 103-05; 104-25

05; 105a-05; 109a-05; 110a-05; 111a-05; 112-05; 113a-26

05, Resolveds 1-5, 6; 114a-05; 115a-05; 116a-05; 117a-27

05; 119a-05; 120a-05, Resolveds 1-3; Report A-2-05; 28

503-05; 506a-05, Resolveds 1-3; 509-05; 510a-05; 29

515a-05; 516-05; and Report E-2-05 BE RENEWED 30

AND THAT POLICIES 101a-05, Resolved 2; 113a-05, 31

Resolved 7; 120a-05, Resolved 4; 506a-05, Resolved 4; 32

and 521-05 BE ALLOWED TO SUNSET. 33

34

This concludes the report of Reference Committee E. I would like to thank the CMA 35

members who testified; our Committee members, our Committee members, Ameena Ahmed, 36

MD; Stephanie Booth, MD; Michael Cedars, MD; Robert Edelman, MD; Manmohan Nayyar, 37

MD; James Washington, MD; and our CMA staff, Lisa Matsubara and Patti Moyle. 38

39 40

__________________________ 41

David Bazzo, MD, FAAFP, Chair 42