REFERENCE COMMITTEE E

Quality, Ethics & Medical Practice Issues Item No. Resolution(s)/Report(s) Page No.. 0-: PHYSICIAN ASSISTED SUICIDE 0-: PHYSICIAN ASSISTED SUICIDE. 0-: DISABLED PARKING PLACARD ABUSE. 0-: DISABLED PARKING PLACARD ABUSE. 0-: CURES DATABASE. 0-: CURES DATABASE ACCESS. 0-: CURES DATABASE ACCESS BY LAW ENFORCEMENT. 0-: EHR INTERFACE CONNECTIVITY AND INTEROPERABILITY. 0-: REVIEW AND RESPOND TO THE PERILS OF EHR. -: IMPROVED MEDICAL RESPONSE TO CHILDHOOD BULLYING. -: TREATMENT OF MINORS IN PSYCHIATRIC FACILITIES. -: OPPOSING PROLONGED SOLITARY CONFINEMENT. -: DISCIPLINE FOR PHYSICIANS MAKING FALSE CLAIMS USING MASS MEDIA. -: HOSPITAL JOINT VENTURES WITH CORPORATE PHYSICIAN PRACTICE MANAGEMENT GROUPS. -: PRESCRIBING USING TELEMEDICINE. E--: POLICY SUNSET REVIEW

REPORT OF CALIFORNIA MEDICAL ASSOCIATION HOUSE OF DELEGATES October -, 0 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. 0 0 Members of the CMA House of Delegates: The reports and resolutions referred to Reference Committee E have been considered by our Committee, which met at :0 PM via UberConference and Telephone Conference in California on October, 0. Members of the Committee present include: David Bazzo, MD, FAAFP, Chair; Ameena Ahmed, MD; Stephanie Booth, MD; Michael Cedars, MD; Robert Edelman, MD; and James Washington, MD.. Resolution 0-: PHYSICIAN ASSISTED SUICIDE Author: Richard N. Gray, Jr., MD RESOLVED: That CMA s policy regarding physician involvement in patients desire to end their lives be limited to certification of their having a terminal illness and certification of their capacity to make medical decisions. Resolution 0-: PHYSICIAN ASSISTED SUICIDE Author: William S. Andereck, MD, FACP RESOLVED: That physician participation in willingly assisting or participating in a patient s death, beyond ascertaining diagnosis, prognosis, and mental capacity, is fundamentally incompatible with the physician s role as healer; and be it further RESOLVED: That CMA will continue to oppose efforts to involve physicians in willfully ending life; and be it further RESOLVED: That CMA will remain neutral on end of life options for competent, terminally ill patients that do not involve the participation of physicians. APPROVAL OF THE FOLLOWING SUBSTITUTE RESOLUTION (FOR RESOLUTIONS #0- AND #0-) AND ASKS FOR A "YES" VOTE ON IT.

Page REPORT OF 0 0 0 RESOLVED: That CMA advocate for liability protections for the physician decision to participate or refuse to participate in physician aid-indying. A. Current CMA policy is neutral on physician aid-in-dying (PAD). Given the multiple views and perspectives expressed by CMA member physicians as evidenced by () CMA member survey; () the Council on Ethical Affairs report; () Council of Legislation report; () comments from CMA members and delegates of CMA's House of Delegates in response to the CMA Speaker's solicitation of input on PAD and SB ; and () the Board of Trustees' action on the PAD policy and legislation, the current position should be maintained. B. CMA policy does not include liability protections for physicians who elect to participate or refuse to participate in physician aid-in-dying. This recommendation clarifies CMA s intent to protect physician members regardless of their level of participation.. Resolution 0-: DISABLED PARKING PLACARD ABUSE Author: Robert Bitonte, MD RESOLVED: That CMA support legislation increasing penalties for disabled parking placard violations; and be it further RESOLVED: That CMA support legislation increasing the enforcement of disabled parking placard codes. APPROVAL OF RESOLUTION #0- AS RESOLVED: That CMA support increasing penalties for disabled parking placard violations; and be it further RESOLVED: That CMA urge the Department of Motor Vehicles (DMV) and law enforcement to increase the enforcement of disabled parking placard codes. A. Increased penalties and enforcement of disability placard violations will act as a deterrent to disability placard abuse. B. Reducing abuse and misuse of disabled parking placards would increase access to designated parking spaces to disabled individuals with a legitimate need for the accommodation.

Page REPORT OF 0 0 0. Resolution 0-: DISABLED PARKING PLACARD ABUSE Authors: Janet Lord, MD, Jeffrey Young, MD RESOLVED: That the criteria for a disabled parking placard (and the relevant form) be revised to include purely functional criteria, i.e. limitation of independent ambulation to less than one city block or 0 yards, regardless of a medical practitioner s signature; and be it further RESOLVED: That this matter be referred for national action. DISAPPROVAL OF RESOLUTION #0- AND ASKS FOR A "NO" VOTE ON IT. A. Amending the criteria for disability certification to include purely functional criteria removes physician discretion in certifying a disability that necessitates a disabled parking placard. B. Restrictive criteria to obtain a disabled parking placard could prevent patients with legitimate needs that may not fall under the purely functional criteria from obtaining a placard.. Resolution 0-: CURES DATABASE Author: Humboldt-Del Norte County Medical Society RESOLVED: That CMA work with the Department of Justice and the CURES Database to allow physicians to access reports to identify all medications that have been ordered under their DEA number. APPROVAL OF RESOLUTION #0- AS RESOLVED: That CMA work with the California Department of Justice to allow physicians to access and review controlled substance prescribing history recorded under their own DEA number in the CURES Database. A. Physicians currently do not have access to their own prescriber activity reports in CURES.

Page REPORT OF 0 0 0 B. The ability to access and review their own prescriber activity reports in CURES would allow physicians to evaluate their own prescribing patterns, identify any fraudulent use of their DEA number and provide an opportunity to correct inaccurate information in CURES. C. The substitute makes changes to reflect scope of information maintained in CURES.. Resolution 0-: CURES DATABASE ACCESS Author: Roneet Lev, MD RESOLVED: That CMA support legislation that would allow CURES access to a physician medical director of health plans, methadone clinics, and medical organizations that are involved in paying and dispensing prescriptions for the purpose of promoting safe prescribing, preventing doctor shopping, and informing prescribers when a patient is obtaining medications that can pose a danger. DISAPPROVAL OF RESOLUTION #0- AND ASKS FOR A "NO" VOTE ON IT. A. The law already allows physician medical directors of health plans, methadone clinics and medical organizations to access CURES to provide care to a patient. B. Allowing access to CURES for any other purpose other than providing care to a patient raises privacy and confidentiality concerns.. Resolution 0-: CURES DATABASE ACCESS BY LAW ENFORCEMENT Author: Roneet Lev, MD RESOLVED: That CMA support the ability for the California DOJ to accept administrative subpoenas and not require the criminal search warrant or court order for the purpose of running a CURES report on patients who may be doctoring shopping. DISAPPROVAL OF RESOLUTION #0- AND ASKS FOR A "NO" VOTE ON IT. A. Patient prescribing data in CURES contains sensitive medical information that may reveal a patient s underlying medical conditions. B. Allowing law enforcement to access patient data in CURES without a warrant or court order raises privacy and confidentiality concerns, including potential constitutional issues related to warrantless search and seizure.

Page REPORT OF 0 0 0. Resolution 0-: EHR INTERFACE CONNECTIVITY AND INTEROPERABILITY Author: Christopher Lundquist, MD RESOLVED: That CMA support the concept and critical need for regional and state programs and exchanges that provide secure and affordable electronic health record (EHR) interfaces for sharing vital medical information between health care providers and health care entities. APPROVAL OF THE FOLLOWING SUBSTITUTE RESOLUTION (FOR RESOLUTION #0-) AND ASKS FOR A "YES" VOTE ON IT. RESOLVED: That CMA support local and state programs that enable secure and affordable electronic health record interfaces for the exchange of health information between health care providers. A. EHR systems do not necessarily interface with each other and are costly to implement. B. Increased interoperability of different EHR systems facilitates efficient, timely and coordinated patient care amongst health care providers. C. Existing policy already addresses supporting efforts to improve the exchange of information in EHRs between health providers.. Resolution 0-: REVIEW AND RESPOND TO THE PERILS OF EHR Author: Michael W. Fitzgibbons, MD RESOLVED: That the government suspend requirements for implementation of EHRs and ICD- (which will slow physician productivity) until studies have been completed that assess the reduced access to care, the alteration in the physician-patient relationship and the reduction in personal interaction between physician and patient; and be it further RESOLVED: That CMA request a study be performed by the appropriate agency to determine the impact of implementation of EHR on physician productivity. APPROVAL OF RESOLUTION #0- AS

Page REPORT OF 0 0 0 RESOLVED: That CMA request a study be performed by the appropriate agency to determine the impact of implementation of electronic health records on the patient-physician relationship and physician productivity. A. Considering the high number of incentive payments that have been awarded to physicians, many may not be willing to abandon the incentive program in its entirety. B. After many delays, ICD- took effect October, 0. C. In 0 RAND/AMA reported on physician perception of the quality of care and use of EHRs, finding that EHRs were a source of both promise and frustration, with major concerns about interoperability between systems and the amount of physician time involved in data entry.. Resolution -: IMPROVED MEDICAL RESPONSE TO CHILDHOOD BULLYING Authors: George Fouras, MD, Walker Keenan RESOLVED: That CMA encourage physicians to include peer bullying in any screening for adverse childhood experiences that they provide to California youth, and that quality screening tools and referral resources be made available to clinicians wherever needed and appropriate; and be it further RESOLVED: That CMA calls upon California s Governor and Legislature to enact a comprehensive program that requires local education agencies to adopt policies that prohibit student discrimination, harassment, intimidation, and bullying and to train school personnel in compliance with such policies. APPROVAL OF RESOLUTION #- AS RESOLVED: That CMA encourage physicians to consider peer bullying in any screening for adverse childhood experiences that they provide to California youth, and that quality screening tools and referral resources be made available to clinicians wherever needed and appropriate; and be it further RESOLVED: That CMA supports efforts encouraging local education agencies to adopt policies that prohibit student discrimination, harassment, intimidation, and bullying and to train school personnel in compliance with such policies.

Page REPORT OF 0 0 0 A. The prevention of bullying and other violent or aggressive behavior can be reduced through universal school-based programs, and the physician can help play a role in prevention. B. There are already California laws in place to address bullying, but more could be done.. Resolution -: TREATMENT OF MINORS IN PSYCHIATRIC FACILITIES Author: Jason Bynum, MD RESOLVED: That CMA support the involvement of legal guardians and/or parents in the treatment of minors receiving services in psychiatric treatment programs; and be it further RESOLVED: That the voluntary placement of minors in psychiatric facilities be encouraged; and be it further RESOLVED: That the involuntary placement of minors in psychiatric facilities be used only in emergency circumstances with appropriate legal justification. APPROVAL OF RESOLUTION #- AS RESOLVED: That CMA support the involvement of legal guardians and/or parents, when appropriate, in the treatment of minors receiving services in psychiatric treatment programs, under a 0 hold; and be it further RESOLVED: That CMA support the creation of a uniform state standard for who can generate, enforce, release or continue a 0 hold. A. It is not uncommon for legal guardians and/or parents to be told, erroneously, that the treatment of their minor is confidential due to the minor being placed on an involuntary hold. B. California has counties and each county has different requirements as to who can generate, enforce, release or continue a 0 detention. C. A uniform state standard as to who can generate, enforce, release or continue a 0 hold for minors would ensure the protection of a minor s due process rights.. Resolution -: OPPOSING PROLONGED SOLITARY CONFINEMENT Authors: Ameena Ahmed, MD, George Fouras, MD,

Page REPORT OF 0 0 0 Pratima Gupta, MD RESOLVED: The CMA supports limiting the use of long-term solitary confinement to no more than 0 days in adults and hours in minors, due to the profound psychological suffering it causes; and be it further RESOLVED: The CMA support prison physicians and other health care professionals who advocate for their patients to be removed from or not to be housed in Security Housing Units; and be it further RESOLVED: That this matter be referred for national action. APPROVAL OF RESOLUTION #- AS RESOLVED: The CMA supports limiting the use of long-term solitary confinement of inmates and ending the practice of solitary confinement of minor inmates, due to the profound psychological suffering it causes; and be it further RESOLVED: The CMA support physicians and other health care professionals who advocate for their patients to be removed from or not to be housed in such Security Housing Units ; and be it further RESOLVED: That this matter be referred for national action. A. Solitary confinement has psychological effects on prisoners that can have lifelong consequences. B. Physicians, as health care providers, have an active role in ensuring no harm comes to inmates. C. National trend supports solitary confinement reform. D. Removing references to specific maximum periods provides CMA with more flexibility in advocating this issue. E. Referral for national action is appropriate because the AMA does not have policy on the issue on long-term solitary confinement.. Resolution -: DISCIPLINE FOR PHYSICIANS MAKING FALSE CLAIMS USING MASS MEDIA Author: Jeffrey Young, MD RESOLVED: That CMA require physicians who make public statements about health and science to disclose whether their positions are based on published peer reviewed evidence, standard of care, or personal opinion; and be it further

Page REPORT OF 0 0 0 RESOLVED: That CMA encourage state licensing boards to impose disciplinary procedures against doctors who make false public statements using mass media; and be it further RESOLVED: That this matter be referred for national action. APPROVAL OF RESOLUTION #- AS RESOLVED: That CMA encourage physicians who make public statements about health and science to ensure that their positions are supported by published peer reviewed evidence or evidencebased principles, and include disclosures of any potential conflicts of interest; and be it further RESOLVED: That CMA encourage state licensing boards to impose disciplinary procedures against doctors who recklessly make or disseminate false medical information using mass media. A. There are significant potential health repercussions for individuals who do follow nonevidence-based medical advice. B. Physician penalties for failing to disclose conflicts of interest may incentivize more transparency from controversial media doctors. C. As amended, resolution broadens support for effective measures from relevant regulatory bodies and alliances that focus on physician professionalism and sciencebased medicine. D. Aligns with existing AMA policy that calls for a report on the professional ethical obligations of physicians in the media, and how unprofessional conduct in the media may be disciplined.. Resolution -: HOSPITAL JOINT VENTURES WITH CORPORATE PHYSICIAN PRACTICE MANAGEMENT GROUPS Author: Tom Sugarman, MD RESOLVED: That CMA immediately make it a high priority to immediately investigate and research the legality of both the joint ventures between corporate physician practice management groups and hospitals and the structure of corporate physician practice groups; and be it further RESOLVED: That CMA will investigate Stark compliance, potential fee splitting, and possible violations of the corporate practice of medicine bar under joint venture agreements between hospitals and corporate physician practice groups; and be it further

Page REPORT OF 0 0 0 RESOLVED: That CMA generate a report based on the investigation and refer to the Board for appropriate action within California and refer to the AMA for national action. APPROVAL OF RESOLUTION #- AS RESOLVED: That CMA encourage both investigation and research into the legality of hospital arrangements, including joint ventures, that may have a negative impact on patient care and physician independent judgment; and be it further RESOLVED: That CMA encourage investigation of Stark compliance, potential fee splitting, and possible violations of the corporate practice of medicine bar under hospital arrangements, including joint ventures, that may have a negative impact on patient care and physician independent judgment; and be it further RESOLVED: That CMA make available to CMA members updates on advocacy efforts regarding hospital arrangements, including joint ventures, that may have a negative impact on patient care and physician independent judgment and report this issue to the Board of Trustees for appropriate action. RESOLVED: Refer, if appropriate, to the AMA for national action. A. Existing CMA policy already provides for scrutiny of hospital arrangements, including joint venture arrangements. B. CMA currently is engaged in activities that will investigate the legality of hospital joint venture arrangements. C. The amendment updates existing CMA policy to adapt to the current healthcare market. D. In order to provide updates on CMA advocacy efforts on this issue, information can be made widely available to CMA members through CMA Alert, newsletters, and the CMA website.. Resolution -: PRESCRIBING USING TELEMEDICINE Author: Michael Borok, MD RESOLVED: That CMA advocate that the Medical Board of California construct telemedicine regulations that state that a physician cannot prescribe a medication without first establishing a defined physician-patient

Page REPORT OF 0 0 0 relationship that includes establishing a diagnosis through an examination performed during a face to face encounter. REAFFIRMATION OF POLICY (BOT 0--:) IN LIEU OF RESOLUTION #-. A. California state law requires an appropriate prior examination prior to prescribing medication. B. California and federal law does not require the examination to be in-person and allows for the examination to occur via telehealth, using a two-way, real-time interactive audio and video communication system. C. Recently adopted CMA policy on the Principles of Telemedicine already addresses establishing a physician-patient relationship prior to the use of telemedicine. It states that "[a] physician-patient relationship must be established, through at minimum, a face-to-face examination, if a face-to-face encounter would otherwise be required in the provision of the same service not delivered via telemedicine. The face-to-face encounter could occur in person or virtually through real time audio and video technology." (BOT 0--:).. Report E--: POLICY SUNSET REVIEW THAT POLICIES a-0, Resolved ; -0; - 0; a-0; a-0; a-0; a-0; -0; a- 0, Resolveds -, ; a-0; a-0; a-0; a- 0; a-0; 0a-0, Resolveds -; Report A--0; 0-0; 0a-0, Resolveds -; 0-0; a-0; a-0; -0; and Report E--0 BE RENEWED AND THAT POLICIES a-0, Resolved ; a-0, Resolved ; 0a-0, Resolved ; 0a-0, Resolved ; and -0 BE ALLOWED TO SUNSET. This concludes the report of Reference Committee E. I would like to thank the CMA members who testified; our Committee members, our Committee members, Ameena Ahmed, MD; Stephanie Booth, MD; Michael Cedars, MD; Robert Edelman, MD; Manmohan Nayyar, MD; James Washington, MD; and our CMA staff, Lisa Matsubara and Patti Moyle. David Bazzo, MD, FAAFP, Chair