Transcripts For SFGTV Health Service Board 3817 20170313

Matters . There is no further business. Thank you so much, good afternoon, everyone. Thank you very much. February 21, 2017. Motion to approve. Second. Heard a motion to approve and second for the minutes of february 21. Any corrections to the minutes at this point . If not we are prepare frd the vote. All in favor of the minute say aye. Aye. Opposed . The minutes are approved. Item 3 is directors report. Good afternoon commissioners. You have drethers report in front of you but because it is so timely we would have director of policy and planning come up and talk about details of the aca repeal and replaced legislation called the American Healthcare act. So, colleen. Please. And any items that you have questions on the directors report happy to answer. Good afternoon commissioners. As you may have heard yesterday the House Republicans introduced the American Healthcare act. It is two bills that will be taken up sime ultaneously in committee tomorrow or not sime ultaneously but currently in two committees tomorrow. It is on quite a fast track. It looks like it might get to the floor the house by the week the 20th and perhaps ovto the senate by the week of the 27th. I have in your directors report a summary oof the key elements of the proposed legislation and can go through a few of them. There are many elements and it is all still under analysis, but some key ones related to department of Public Health. Both of the mandates would be eliminatedpenalties for both mandates, individual and employer mandate will be eliminated under the bill. On the replacement side, there would be a Continuous Health Insurance Coverage innocentive for individuals. It is more of a disincentive. There is 30 percent surcharge allowed for people who didnt keep continuous coverage. On the employer side it also delays implementitation of the cadillac tax, so trying to show the table that you have tries to show the aca component repealed and replacement aftered as the plan. Medicaid expansion, it as you recall the Medicaid Expansion expanded health inshurn to single dultess up to 138 percent the fram poverty level. The bill would resend that expansion. The effective 2020 and eliminate enhanced federal match. After that states would be able to include them in their own plan given additional flexibility by the federal government, but the enhance match in federal funding will not follow suit. The next item on the table is not an item that had a aca component but a major change that being recommended by the legislation and that is the transition of the medicaid financing system frafrom a federal matching where the state spend a certain amount of money and get a matching percentage from the government for Eligible Service and population. Changing to a per capita cap so it would be calculation based on the the spinge type of enrolly and cost incured by the state for those types of enrollees in 2016 multiplied by the numberf oenrolleeess in the state and that is the amount of money that is allocated to state for medicaid. The others are income based tax credits so right now on coved california there are credits that make helt 234 shurns more affordable for low income people. Those tax cradts would no longer be calculated on income but calculated based on age. The cost sharing subsidies, there are also on covered california cost sharing suxdies to individuals who are low income. Instead the proposed bill will create a patient and state Stability Fund that would give states flexibility to use this money for high risk pools, payments to insurers or providers or other affordability measures. Under the disproportionate Share Hospital program, commissioners may remember that program is scjed to sunset. It provides funding for hospitals that provide disproportionate share of care to uninsured and medical beneficiaries so in this scenario the dish funding is restored. That sun set date would be eliminated and our state restored in 2020. The other key element i have is essential Health Benefits. Commissioners may remember there is a standard set of Health Benefits that are included in the Affordable Care ac. This would eliminate the minimum coverage requirement effective twept 2020 and increase flexibility for states. It should be noted too that it would retain protection for preexisting conditions and allowing young adults to be coved on the parent helths insurance until age 26. There are many more provisions, it is all still being analyzed but wanted to give you the top line points for your consideration today. While we keep tracking the change and have a executive conversations how 2450es impact and this is a changing environment so how these impact the department and city as a whole so as we learn more we will bring as much information to the commission as possible. Yes. Commissioner pating and also want to thank colleen whiching quickly because this was just released yesterday to come with quick analysis. I would assume also director that we would be kept up to date on whatever chaichcks occurred as the debate continued or as you are now escalating the timeframe that i had heard and it sound like they are trying to get this done before the end of the month . It sound like it can go to the senate for consideration before the april recess. Before the april recess, but potentially then whatever were to occur would probably occur after the april recess with the senate, right . I believe thats true but not certain. Just looking at a timeframe if it get through the house fairly rapidly has you were projecting looking at what might be a final product and what we might be able to see, that might not be until like the end of april . I dont know whether it is able to take it before the april recess but i know that the current intention is get it. They are not sure they can get it there before recess. Just looking at a time frame if they were able to move on the fast track is about near the end of april probably . I would imagine and alsop to say the medicaid provision which are the most significant provisions for it Health Department are not scheduled to take place until 2020 so there is passage date and implementation date. The Effective Date wouldnt be until 2020 for many provisions. Now i take comments from the commissioners and start with commissioner pating. Ish oo as that may effect the county. The 34ed cade expansion going from 90 to 50 percent in 2020, i would assume this is essentially Cost Shifting to the state since the states have to pick up the gap if the Services Continue at that level chblt. Is that the way you read that reducing the medicaid federal match . I think there is that but also the per capita cap conversation so the way the per capita cap is calculated would not include Medicaid Expansion so the previously eligible enrollees and not include the Medicaid Expansion and that is also a cost saving measure for the bill at the federal level all together so it would be reduction because that is the intention of the capita cap shift. The change in methodd for the states so estimateds much as 10 billion reduction in federalfunding. Okay. For california, which may be less monies or the county would be responsible. That would be a negotiation that would happen between the states and counties i would say. Just like counties dont necessarily have the funding to absorb what is otherwise the cost, the state doesnt have enough fund toog absorb the cost so something that will happen in the california legislature. The implementitation with dish funding would the hospitals gain funding for uninsured care . The scheduled reductions will be eliminated. Lastly, essential benefits, do you know the status of mental helths and substance abruce and prepregnancy planning and essential benefits . Jerk , i have seen summaries it eliminated requirement for essential service including melthsal helths. Just every Commission Meeting as much information as we receive well continue to update you like this. Yes. Thank you. Commissioner chung. I dont think this is something to have a answer now, but with the Medicaid Expansion they also have changed the eligibility guidelines also. Correct me if i was wrong, if somebody actually drop out of Medicaid Expansion they cannot reenroll, is that correct . So, my understanding is that they cant reenroll at the enhanced rate. Between now and 2020, betweeni dont know the start date would be from now to 2020 say, if a person was enrolled in a medication expansion we currently receivebe receiving 90 percent federal fund, 10 percent local fund. If a person loses coverage between now and then it drops to 50 50 rate. So thats one of my big concerns also setting the eligibility kind of people in anxiety most of the time and worry about the income go over the Eligibility Criteria and i knoe people would actually try to stay under employed to not lose services and dont think that is innocentsive at all so something maybe we should have a conversation about like what other ways we can do to help people who have to decide to transition out of like the Public Benefit system. Related to that, the bill also include a provision for sem iannual redetermination for medical. Versus anual. How exciting. Sorry. Commissioner sanchez. Y i want to thank you very much for bringing this up to date on the latestbasically want tosay we are trying right now, the house input and what they are presenting between the two committees. The environmental and congress and from there as you said, there is a whole different protocol they are trying to expedite but still need to gothe next step is budget, after that it is rules committee and then the full house and then they will probably take the recess or whatever because the senate has a significant theory, some [inaudible] this is ryans he is holdingi dont know what they have been doing 7 years but it certainlyanyway, all im saying is i think that there will be i think really pronounced changes i hope. I think that some people in the staffers in the senate side and those looking forward to a joint Conference Committee which will take a great deal of time between both sides when it gets to there, i think we may see changes but i was surprised to stee the projected dates that i think they were talking short term, now 2020, 2024. Before that wasnt on the radar when they were initially discussing what in fact they may do because he wanted things snapped to. It does chbt work that way. With the dance of legislation there is a lot of things that will be coming up and i really think that the senate staff and our senators have some really hopefully unique contributions where we could sort of at least present this to the best interest of all people rather than what they are trying to do through here. Again, i just think this was a excellent summation. As i said it is like the first draft proceeding within the Clinical Trials and both side meet and again and again and well have whatever comes out if it passes. Thank you very much. Thank you. Commissioner loyce. Thank you for your report and agree with my colleagues. What we see today and what will be the final bill are distinthly Different Things but there are core issues the things paul ryan and voltmorted they wanted to do after they got elected so very interested to see what the final piece of legislation looks like. Thank you for updating this and keeping us updated in term s of the changes that will occur. The value of the Medicaid Expansion for california is about 15 billion and the amount of the reduction that would occur because och the per capita cap is not yet known because the rates are not clear how they will calculate it is not clear so likely on top of the loss to california would likely lee addition for per capita cap and Medicaid Expansion. Thank you. Thank you. Well, we cant say too much more beyond that at this point as commissioner sanchez sayatize will probably continue to be modified as it goes through. We will be updated as the changes occur. Yes, commissioner chung. I think we should also track the single payer bill going through sacramento also. I think what we will do is incorporate in the discussion what is happening at the state level in the response. The legislature as i understand it had said it wasnt going to take up anything until a bill came out. The bill has now come up. Meanwhile a single payer bill is put into the coffer. Does that make sense that we can also see what californias response is to this new bill as the possible solutions to keep us up to date . Okay. Thank you. Was there any Public Comment on this . No Public Comment request for that item. Okay, then we will move to the next item general Public Comment and there is one. Mr. Knight, please and you have three minutes, please sir. Mr. Wrightile rur ill say 30 seconds when it is time to wind down. Im here 250 talk about a major problem going on year after year afteryear for the past 25 to 30 years. It is pertaining to continue homelessness of people who are economically disadvantaged and got accomodation of mental and physical disabilities. By the same response also applies to our veterans. Jest yesterday [inaudible] is proposing and requests 200 million for programs engineered and targeted for homeless peachal. The point i want to expose to you is that the city has been responding millions and millions of dollars on shelter services, programs, shelters and homeless programs, when the truth of the matter is, the people navigate for need permanent housing just like you do. Now, the below market rate housing opportunities that comes from the Mayors Office on Housing Starts to requirement eligibility for people to be eligible to apply at income level where the target of people who are homeless or not even qualified to apply. Thats why you keep having the major problem of homelessness in the streets and as a result, this repeatedly wasted millions of dollars on these programs such as Navigation Centers is not going to be a solution to the homeless problem. That money should be spent on renovating several sets of vacant buildings that is owned by the city and converted into low Income Housing for the people who you trying to help. Now, here to speaking about this to the Health Department because it ties into the Health Department because the Health Department is spending millions of dollars as well on people who are using substance abuse, alcohol abuse and being picked up for the ambulance i taking to San Francisco General Hospital and additional millions of dollars is being spent at General Hospital by the medical staff. So, i urge you to try to unit with the Mayors Office and board of supervaseers and spend the money building permanent housing for people in the income bracket like you do fl the people in the higher income brackets. Any questions . Thank you rks mr. Wright. There are no other requests. Okay. Thank you very much. We can move to the next item which is rart back from finance and Planning Committee. Commissioner chung, please. Good afternoon commissioners. The finance and Planning Committee met before the Commission Meeting today and we had approved a set of contracts and also contract reports that are added to the consent calendar for commissioners to consider and approve. But on those consent calendar items i like to draw your attention to item number 2 ichb the consental calendar which the contract that needs to be approved. That item we are going to move ahead and approve two of the five contracts that total 2 million and it is for the low Voltage Services and not the general contracting which belong tooz the other three businesses. That part of the contract is wurkt 4 million drz but we are differing that to maybe the next finance meeting to reconsider those contracts. Ologist, also, we heard a presentation from mr. Wagner on the revenue and expenditure for the Second Quarter and the committee has decide that we are going to continue to have presentations quarterly on the revenue and expenditure report, but also that would come to the commission twice a year and that way we are hoping to improve on the budget and also like and Running Commission businesses and so it will come to the commission on the Second Quarter as well as the Fourth Quarter and if commissioners are interested in participating in any discussion like every three months, please join us and you are always welcome because it is a Public Meeting at the finance and Planning Committee. Commissioner, any questions on that and to reemphasize in the past the quarterly reports have been brought to the commission directly. It was felt by the finance committee they like to see the quarterly reports at the meetjug today was the first time we brought that to the finance committee. The finance committee is recommending it is appropriate that thesemiannually on the second and 4th quarter the department would also formally report to the commission but each quarter it submitathize report to the finance committee for its comments. Thats a recommendation that we would follow unless there are questions and a concern from commission members. Having to sit on the finance Planning Committee i support the motion and allows a nice balance between the finance committee doing indepth rerue and full commission seeing the larger picture on a semiannual basis so a good compromise. Any other comments . If not we will agenda the Second Quarter report for this year to the full commission at our next meeting. Thank you. There are no Public Comment requests for this item. Thank you. Then well proceed on to the consent calendar. Ill remeend you that commissioner chung noted that the request for approval of 5 new contracts for as needed Facility Maintenance services has been changed and you are differing 3 of the contracts and considering approving 2. Otherwise the remaindser othf contracts are before you. Any abstraction frz the commission to discuss . If not we are prepare frd the vote on the consent calendar. All in favor of the consent calendar say aye. Aye. Opposed . The consent calendar is adopted. Thank you very much. Item 7 is Health Commission elections. Yes. Commissioners, the Health Commission is normally scheduled on the second meeting of march following march 15 to hold Commission Officer elections, however, because of a issue of either new or reaopponentment of commissioners has not actually occurred and several commissioners will be away during that day. Im proposing that we move the elections to the first meeting of april. We would need a motion for that. So moved. Is there a second . Second. Is there further discussion . If not all in favor say aye. Aye. Opposed . The election of officers will occur the fist meeting of april. The date is prl 4. April 4. Iletm 8 is update from it. Mr. Kim. Good afternoon commissioners, bill kim recollect chief information officer. Today ill presenting to you our it update. Todays update largely will focus on our effort at Electronic Health record. I like to go over the following items on the agenda. We will go over forward approach, timelines, what our approach is, as well as key Critical Paths that we are working on today. As well as cover some of thecover a question brought up by commissioner regarding the impact of meaningful use due to the 6 month delay to the new timeline. At the end we will also present to you the 10 year total cost estimate broken down by year. It should be noted that the total cost is a estimate at this time because we have not selected a ehr and continuing to do Due Diligence on the efforts required. Most of you have seen this slide before. As you recall, this is the high level strategic approach to obtaining the meeting the goals and mission of dph which is at the top the roof. You notice that the foundation which is in gray, which is the infrastructure is circled and two pillars that support our erft. Currently, we are in the green box, we have been working very hard on the purple and the gray and we are in schedule doing all those. As you can imagine, some of those items such as right solutions equate to rfp and other related work efforts. The purpose of this slide here is to just give you a frame of reference as to the continuity of our approach. Commissioners, this slide is the overall dph timeline. You notice that the lanes that represent various tracks have three different colored bars. That is to show you the original timeline, the previous timeline and the current timeline of the work effort. This is the overallone thing you note if you go back to the previous presentation is drh, rfp and contracting is consulidated into one swim lane to show a continuous effort opposed to two different efforts. This is actually athis timeline shows just the two primary timelines that we are engaged in today. They are the improving the it and preparing the organization for the ehr as well as the ehr, rfp and contracting. This is the current work effort that we are largely engaged in. As you can see, the timeline has shifted a little bit because of the rfp effort we are undertaking that i shared with you at the beginning of the year. Please note that the legend i also added couple of notations, so instead of saying preebious timeline now it says previous timeline with rpf, baseline timeline withu csf and current timeline with rfp because it shows why the timeline changed. Theu csf timeline changed about 6 months due to the current timeline of the rfp. Please note all the timelines will show go live date or go live 1 and go live 2. These are the ehr implementation and go live schedule. We anticipate we will be done with the contracting by end of 2017 and we will build the ehr in parallel for phase 1 and phase 2, however, phase 1 will go live 6 months prior to phase 2. Phase 3 which are all the other layering technologies, will continue on and the reason why that is important is we would like to make sure that we focus on the fact that once we have invested in erh and purchased it wewill continue to optimize and get the value for our investment. Now, regarding the current effort, this is the very busy slide, but i would like to go over the three major aspect of this. The team are the actual teams engaged in the work effort. As you can see, not only is all dph involved but we have other agencies including the legal as well as dpw engaged in helping us meeting the readiness of the ehr. I wont go through every 1 of the colorful boxes but you can see what the are. The current effort are Critical Path. In order for us to successfully select contracts and implement the ehr we must have these three key tactical objectives accomplished. Number 1 is timely procurement of best fit ehr. As you could imagine, we will need to have a very competitive process which is very lets say it take as lot of effort on a lot of peoples part but we are commit today a competitive Selection Process and the way we accomplish this is erh rfp out in the market place and we are already getting responses from vendors. The next item is readily available for as needed assistance and by the way, i will go over in detail what they mean because they do require some clarification. Namely, this is a Critical Path because we as a city agency as many other city agencies doeswe do have to gowe have a long lead time in procuring resource squz want to make sure that when a resource is required, that we will have them. We will be doing this through a rfq recently released. We will also practice budget governance and governance of the scope. The third track is the implementation and adoption readiness. We do have gaps. We have gaps in governance and process and process structures and we actually have identified 14 specific go for initiatives that we are engaged in today to actively insure that we are ready to implement, adopt and get the most value ue out of our ehr investment. Okay, so Critical Path to success number 1. Timely procurement. Please note the timeline for the specifics of the effort related to the rfp. This is here it give a level of transparency as to the work effort involved and timeline involved in the rfp. It should be noted we have a more detailed version of this with much more items, however i feel this is a good level for you to understand in terms of the key dates that are associated with the rfp. The Critical Path 2, readily available as needed assistance. This is really about having the right resources that we will need to implement and be ready and implement the ehr. Not all resources will come from dph internal staff and not all resources will come from dhr vendsers. There will be need for implementitation that involves change management, project management. Consulting for niche products, temporary backfill as we send employees to train or engage in the build. Additionally we need additional technologies that allow us to integrate and migrate information to our new ehr. We know the city process to procure resources could take a long time, therefore, we are working with the Contracting Office and legal as well as other agencies to insure that we could utilize the process that is in place to hire the resources as they are ready and as you can see, we are work ing with contracting, civil service, labor union and business leaders. To manage the work effort around this we have put in place a governance to manage the scope, the budget as well as the approval and the performance of these go forward initiatives. Now, for the Critical Path to success number 3, the 14 goal for initiatives i like to introduce you albert eu, our chief health nrfgz officer to go over the e effort as he is largely leading this effortism thank you. Good afternoon. Albert eu. This initiative is actually not just about successful idoption of the ehr but our ability to maximize value and return from the very long expensive investment comes from not just solution we will contract with, but how ready our organization is and how enabled our employees are. They fall into three big buckets. One is about the ehr program. That is fundamental to insuring the project is on time, on budget and within the scope. There is also operational areas we know we need to integrate, standardize and optimize in terms of efficiency. Medical records is a example. Now we have 4 across our various structural towers and can only be one in a enterprise solution. The third area is infrastructure related mostly in the it deparm but also in the facilities and make sure they have the connectivity to adopt the solution. This is primarily for this coming year. Bring your attention to the areas we target for resources. Some come from internal resources and some from external contracts and consultant in the budget and you will see this in the finance committee for the Health Commissioners for approval over the coming year or so. So, this last slide is here because the Commission Asks us to go back and investigate what the 6 months delay from going from theu csf a pex path to the own path will have a impact on meaningful use dollars. The 3w5u9m line is there is very little impact of the 6 month delay because it is on a calendar year so it wont be a dramatic impact. The meaningful use we collected [inaudible] incentive payment and on the ep, eligible professional part which is physicians side we are on year 3 and 4 of the collection, so the impact is very minimum in terms of meaningful use. The biggest drirfb of the 4 of the collection, so the impact is very minimum in terms of meaningful use. The biggest drirfb of the one million is penalties and goes up from 1, 2, 3, 4 percent to. The delaying the 6 months wont have much impact on the penalty because we are not delaying the ability to report and meet those requirements. There is the big change that we dont know yet is called mac ra, the structure the federal government is imposing on the panealties and there is a lot of unknown and will bring forward once we have a deeper understanding the specificity from the federal government. This is a very high level summary slide of over the next 10 years of what we are projecting as the cost model for this ehr adoption journey broken into two rows. The expenditure is at the moment our best guest until we have a final contract hopefully by there enof the year and second row built in as contingency revenue to allow to address unanticipated gaps or risks as we prepare for the long journey, just bring your attention we do have 70 million in the buck td that gives confidence we have a bit of wiggle room of unanticipated risk. Commissioner happy to answer questions you may have. Commissioner chung. Thank you for the presentation. I have a question, so we just approved a pcd contract last time at the finance Planning Committee so what functionim trying to do some application here. What functions do they play . Which role are they currently in right now . Actually are you roughering referring to this slide . Yes, because it is helpful for me for instance to know like since we approved all the contracts that is working on the dhr it is helpful to know the contractors that we approved how they are performance which function. The pcg is related to the security and privacy aspect of the go for initiative. It should be noted our governance started but the bumic bulk of the contract and resource Senate Estimate has rnt gone through the Steering Committee however there are things happening first as a adhoc because we really need to start the effort because of lead time involved. Thality that is great question how to connect the dots and so as we go in front of the committee with our contracts and why we set this up like this to use the sheet as the mapping for the commissioners to know in which category the contracts are meeting. It is a great question and tried to time it in a way that any contract that came forward from now on you see which pieces it is meeting and the requirements it is meeting. Thank you for the question because it helps us in the process of making it clear as to how we use outside of the vendor. Just for remind the commissioners we spent a lot of time on sole source withu csf and couldnt go forward with multiple reasons, primarily financial so now you see where we are in the rfp process and we are awaiting for theveneders to complete their process and as you can see, the initial proposed review is happening april 15th so not many weeks from now. And also just to note that the staff is really working hard on Going Forward making sure that the Mayors Office and when they touch the contract is ready for the contract and trying to build the pathway to get through that in a timely way. Thank you. Commissioner pating. Thank you very much for the helpful report. Could you turn to the last slide, please, the dollar one. J yes this is the most important. There are two that i mr. Kim. One is the delay and understand a lot of that has been really unavoidable because our negotiations withu c did notwe were not able to come to a workable solution there for no ones particular fault, the alignment want quite right. So, trooiing to assess the impact of delay. When i hear a lot of the preptory process and dont have a contract yet, it is frustrating. I feel to some extent presented by a start up tech firm no product there that we actually can grasp but know you are preparing. My question is what is the impact with the delay with regards to our cost structure . As we delay more say we dont get a good rfp or it takes longer, do costs go up anymore if by pushing this out and or maybe does thatmaybe it gives more time to collect more revenue to apply against the costs. Is there any thought . That is a great question. So, the way i experienced it typically the delay in starting implementation actually saves us money. Thats only this year because we actually have 6 months more while we do the rfp to prepare, which means we have that much more time to get to where we need to in order to implement and means we will be ready. From that perspective it will save us money and will allow us to actually be ready so we dont fail the implementitation. However, having said that, where most people experience increased cost or expenditure is in the year 2 and 3 if we run into delays and typically the delays are because one, we are not ready, which i believe we be redding and two, we are ready we dont make timely decisions and with the current governance process in place and the leadership engagement i do not believe zee a problem in those areas at this time. In realty, it worked out fairly well for us in turchls terms of where we need to be. Related to that, thank your report the penalties are not that great. 1 million verses the 70 million we put into the project i think if it sabes us and have quality at the end i think thats beariable cost. Y it should be noted 1 Million Dollar was the original estimate that we had regardless whether we wnt live in late 2018, which was what the u csf a pesh pex or deit ourselves in mid2019. Dr. Albert you pointed out because it is in the same calendar year for the reporting period it has no Material Impact to the meaningful use, but however, unless the law changes which it can, we are estimating approximately 1 million in fines. Thank you. Page is the timeline. Yes rather than showing all the multiple streamsi forgot what you called it, the lean streams, if you could show one particular timeline with critical incidence. I understand we are between march and april so you should have received vepders letters by now . We received letters of intent from the vendors. At this time i do notd not have the approval to release the names. It should be noted that we have gotten approximately 5 and that theveneders that we expected to respond did respond. I guess for me for future report rather than hearing all about the different capacity buildings you are doing, which are really important, what i really want to hear is know we are on time with the key critical steps and so i am looking at this and not sure which is a key critical step so might ask if you could when you you started to comment by saying you dont know what the product is that we are getting and the biggest pieceremember any ehr Electronic Health record isnt the end, it is the equipment we will be using but and have to get all the staff involved and ready for it. The biggest failures of the ehr is staff isnt ready to take it only so that is quhie it is so important for all the work we do from this. I think you are right, i think this Electronic Health record and the process of getting that on contract i would say is one of my important things im looking at and then i think because these are quarterly reports to you so good footoo know your sense of what you like so we can do this and touch upon one othernow you have a big picture and refer back to this and we can basically focus in on the contract process. More worried about that because some of the processes we dont control so go across the street to city hall so we have to really watch those carefully. I would like your assistance doing that. I think that is important and maybe at the next meeting we bring one of the areas we like to highlight to get a focus on i think the issue you started with today. I was thinking when we saw the San Francisco general timeline we got a sense of there are critical structures that needed to fall into place, the audits, the wiring and so type of timelines i think are helpful here and would trust you build up the whole capacity of the system. And then i say update on finance is a part of the other. Lastly, the smaller question on implementitation go live, this is fine. So the ehr phase one is that going to include inpatient and outpatient at the same time . Acute independent services in my experience going you know multiple kind of clinics, i had been through this before and it is much more chaotic than you imagine and wonner how complicated is phase 1 roll out. Are you doing outpatient and inpatient and Behavioral Health all at once . That is a great question for potential risk. Current go live schedule, the first phase will include all bill sites. That includes csfg, primary care and laguna honda. The reason we group them that way is because of the contract ending june 2020. We want to make sure we have about a year to sort of manage that transition process. Phase 2 will include the non envision building sites, mcah, Population Health clinics, jail Health Service will be then wave 2 because they are not depend on billing. Behavioral health is the third. With that said, the wave 1 is a very intense go live with two hospitals and primary care ambulatory clinics is not a small undertaking as a go live schedule but that is the schedule we have to work with in the one year timeframe. This general timeline we are looking at but if we get to the next few perhaps after the contracting or focus on the key critical events that is what i feel like i need to know we are moving forward. Commissioner pating, you bring up important points. This is indeed a high level picture. We could drill down into all the little pieces. We have a lot of working people putting together a lotf of effort and more than happy to share it. The contract sound like is the most important. We will focus on the contract at the next report. I like to add one more thing that tying back to questions you brought up about go live 1, 2 and 3. Currently Behavioral Health module, the current Behavioral Healthyou want to talk about that . The reason why we pulled the Behavioral Health clinics to wave 3 is because all the ehr solution in the market place do not have great Behavioral Health clinical documentation as you know. They also dopet do great bill toog the state level yet, so we want to make sure when we are red a to go live with Behavioral Health there is a workable solution to the state level as well as sufficient or reasonable clinical documentation and communication rirem requirements of behavioral community. That is quhie that is wave 3 at the moment. Right now we planned that for july 2020. I been working in behavioral heblth and used to be at the back of the bus for a while. Exactly. [laughter]. I would have comments with that as well. It is really difficult because we have a integrated model as you know commissioners and it doesnt help us to know that the medical mainstream does not still accept Behavioral Health as a Mainstream Services so it is important component but just note we still have Behavioral Health system and providers will be able to access the other system that will be there bill toog the state and until they catch tupe the market place we are stuck in the third phase process. Commissioners i think you are happy to know behavioral helths is at every single discussion topic. It is very important to us and that is not something that we lose focus on. If i may i would like to acknowledge both of these individuals who have both bill and dr. Eu with great teams under them and working non stop even before we started the u c process and learned a lot through that process and want to acknowledge all the knowledge that we gained from that u c experience helped to get where we are today. That process did not go to waste at all because we were able to really do a lot of preparation we are ready for today. This is one of our Largest Investments and want to make sure the commissioners have full understanding where we are and so we are open to any how deep you want to go to the details you would like. I know bill and albert are available for continuing to provide you updates like this but do want to acknowledge their hard work and teams here today in the audience. J thank you. Just to echo director garcias comment that is the green box. Requirements assessment. A pex Due Diligence really helped us understand much of that and we are at the right solutions phase. Thank you. So, i think it is clear mr. Kim that what we will need then is sort of such a huge project and this is all most more complicated than the building of zuckerberg, which was all most simple compared to this because of all the different moving parts and all the segments that you have. Yes i think the commissioners are pleased that you put them all together on your slides, but somehow we are going to need to look at some of those critical points that you are looking for, watching timelines. Now we have three different timelines floating around here and that could be fine for the overall and as you do this maybe focus on several of them just like here is the contract timeline and what we are doing. Then what is the next timeline we need to fuelo and the critical points commissioner pating said to see how far we are geing going and where the roadblocks may come and successs will come. Understood. I believe you will be reporting quarterly sph yes. So, as obviously you need the rfp completion to do a lot of that more concretely. The idea of starting to get into some of the focuses on some of the areas such as we just wnt into with the go live 1 and 2 which helped a great deal understanding your vision would be where i think we appreciate being able to see how this is going because you got pieces everywhere throughout the whole department and have a whole house that you are building and we know that you have shown us what the whole picture is we just need to get a little more into the detail for the confidence and somehow a Financial Report related to this would be just as we do with the bond issues and all. Obviously in a different way. Now we are following two different very major projects. The whole bond issue and the ehr as a part the Due Diligence. Thank you very much for all the work your team is doing. Thank you. There is not Public Comment requests for that item. We can move to item 9 which is San Francisco climate and Health Adaptation framework and this is just discussion item and no vote. Good afternoon commissioners. My name is cindy pemerferred and work in the office of policy and planning and also direct our climate and Health Program. For those who are nolt familiar with the climate and Health Program, it was started in late 2010. We received competitive Grant Funding from the cdc. We are one of two cities in the United States both San Francisco and new york city and there is a additional 16 states nationally that have climate and Health Programs. Um, the climate and Health Program is a partnership between the office of policy and planning and the Public Health preparedness and Emergency Response. I want to acknowledge the work of my colleagues that made all the materials that i present to you today possible from ourPublic Health Emergency Response trail daling and tera connor and office of policy and planning, max gara, josh olenjure and max wells. Today i will present on 4 main objectives. I will provide information about the San Francisco department of Public Health climate and Health Program and some of the city wide nish tbs that pertain to Climate Change. I will explain why it is important for Public Health professionals it know about climatechange and projected hemth impacts of Climate Change. Im going toprint past initiatives and highlighted some of our materials from our climate and Health Program and lastly, i will present on our climate and Health Adaptation framework and present on the upcoming strategic activities. See, just to start off withilateal about Climate Change 101. I know you are all probably familiar with this information but just to set the stage, Climate Change is any change in the climate that lasts for a long time. Right now we are experiencing Global Warming. Global warming is from the Carbon Dioxide from burning of fossil fuels including oil, coal and gas. Now Global Warming increasing temperature jz we have been seeing a rise in the average surface temperatures on earth. As these temperatures rise, the gases trap heat and the temperature goes up and this causes vairbiable weather, heat wavers, heavy precipitation, fleding, drought, Sea Level Rise and pollution and all these impacts have significant and cascadeing effects. Just to put what i said into context, globalally we emit 110 million tons of global manmade pollution on earth a day and the heat energy trapped thip atmosphere is compareable to 400 hiroshima atomic bombs a day. Whats important about Climate Change is that it is happening now and not something far off into the future. The last 17 hottest years on record, 16 occurred in the last 2 thousand wreers and for the last 3 years have set record for the hottest temperatures on earth. This next picture here shows a glacier in northernwestern alaska. The picture on the lelft shows the dplashier from 1940 and the picture to the right shows 2005. As Climate Change unfolds, Public Health has a special role addressing it. Typically when we talk Climate Change we you hear two word recollect adaptation and mitigation. Adaptation is sometimes referred to as intervention is how to adapt or prepare for Climate Change. So, right now even if weef stopped emitting Green House Gases into the at mosphere there is enough manplaid pollution trapped in the at fus sphere we see impacts of Climate Change regardless if we slow Green House Gases. So, a lot of what Public Health is doing is preparing for the changes in the climate. Sorry about that. As many know, the San Francisco department of pub health is the largest City Department and has a large footprint. It would be the worlds 13th largest emitter of Green House Gases. We also need to establish best practices within the Public Health infrastructure and that is what we call mitigation. Mitigation is efforts to reduce the use of fossil fuels and effort to slow down Climate Change. This is definitely a challenge. We are tasked trying to provide adequate services to the public and grow and also redouse our Carbon Footprint at the same time. We work with the department of environment one of our sister city agencies that oversee the citys Climate Action plan to help each City Department establish goals and reducing Green House Gases and then there is other city taskforces like municipal Green Building task force and department of health sits on that helps us establish best practices within our infrastructure. This slide gibs a very high level summary of the climate projections that we are expected to see in San Francisco. So, for extrome heat we are expected to see up to 40 extreme heat days by the year 2050 and 90 extreme heat days by 2100. Extreme sheet day in San Francisco is classified as the 98 percentile of temperature over a 10 year span which is 85 degrees for San Francisco and ill talk more about that later in the presentation. Right now we are expected to see Sea Level Rise up to 24 inches boy 2050 and up to 66 inches by 2100. If woe take those increase in Sea Level Rise and look at Sea Level Rise with a big storm or storm surge together, we can see up to 66 inches of flooding by 2050 and 106 inches by 2100. Air pollution is also a copollutant with Carbon Dioxide which is the Major Driving with Climate Change and has the potential to increase harmful exposure to elevate contrations of ozone and pm 2. 5. Through changes in the regional weather pattern and increase in heat. However, there is some uncertainty about exactly how much the air quality will decline. Lastly, we expect to see more weather extremes so more extreme storms. This means more heavy scenarios of heavy downfalloffs precipitation and also more extreme droughts. All these changes in the climate have impablths on health. Sorry about that, i keep going the wrong way here. The next slide looks at the helt impacts of Climate Change and within your packet you should have gotten a handout because i know the slide is a little difficult to see. But this goes over some of the most salient Health Impacts, the effect on exposure and Health Outcomes from these changes and exposuresism. I wone go through all the Health Impacts but will go through a couple examples. When we see Health Impacts from Climate Change we see direct impact and indirect impact. Direct impact would be extreme heat day where we see someone who experiences heat related illness or heat stroke or we can see kind of a meadating impact, where we see temperatures rise we see a warmer winters and warmer springs so changes in vector born diseases. And also see things such as indirect impacts. Indirect impact is Something Like a area experiencing an extreme drought and from that drought we seafood insecurity from the reduction in food output. Also on the slide you i kind of see there is melthal Health Impacts and a lot of kind of inconsequences impact from Climate Change and environmental degidation. There is a lot of compelling evidence Global Warming has exacerbated the drought experienced in serbia and because the drought in syria 1. 5 Million People that lived in rural areas moved to cities and this created a big impact on scars water supply and also sky rocketing food prices so the Climate Change on top of this political rest really had a significant influence to had wars going on now. The next couple slides i will show examples of Health Impact from Climate Change. This first slide shows how rising Ocean Temperatures are making us sick. This slide shows toxic algae bloom from alaska to the gump glf of mix co. This was back in 2015 and actually closed down the fisheries off the coast of San Francisco for 5 months. There was demowic acid fond in fish and shell fish and if humans eat that there could bow severe impacts to health and also because of the neuro toxin fond in the shell fish, the closure of the fisheries can also have a indirect impact to the fisherman who depend on these fisheries for their livelyhood. Extreme heat events cause more death annually in the u. S. Than all other extreme weather events combined and most people in San Francisco dont really think about extreme heat events. Typically we have a very temperate climate but in 2006 there was a study that said San Francisco was especially susceptible to extreme for two main reasons. One, because we have such a temperate climate, people have a difficult time thermo regulating to increase in temperature and second, becausewy have a very old housing stock. Most the housing does not have hvac system or air condition. While we are looking at extreme heat event we activate the heat protocol at 85 degrows is the outdoor temp erature and because the Building Conditions it could be 10 to 15 Degrees Higher in the older unit in the city. Poor air quality leads to both respiratory disease, also including asthma and allergies and cardio vascular disease. World wide there is a health cause from air pollution expected to get worse from Climate Change and this slide shows the world wide air pollution crisis as a Economic Analysis which was released by theu n and shows the global cost of air pollution as a proxy of health costs. In 2015, the u n said the cost of air pollution was approximately 2015, the u n said the cost of air pollution was approximately 3. Trillion and by 2060 that is expected it be 18 to 25 trillion. One important and overlooked impact of Climate Change is the mental Health Impacts. This could be because of disaster or a loss of a very cultural significant habitat or because of chronic stressors. People exposed to climate related disaster may suffer from post traumatic stress, depression and or anxiety. A sig kunt proportion of the individuals will develop chronic psychological dysfunction. While we are all impacted by Climate Change, we will not all be impacted at the same. There are certain subsets of the population that are most vulnerable to Climate Change. This include the poor, elderly, infants rsh children, people with preexisting medical condition squz also the minuteally ill. Reducing Health Disparities is a big part of the Climate Justice ajena and equity is a mornt component of the program and try to address vulnerable populations in all our work. So, this conclude the doom and gloom part the presentation. The good news is there is Many Solutions out there to combat Climate Change and about 2 years ago the lan set which is a medical journal came out with a report an article calling Climate Change one the most pressing helt issues and glaitest opportunity too. Many acs and strategies that product from Climate Change and reduce Green House Gas are good for pub lg health. The next part the presentation i will highlight the climate and Health Program past initiatives. So the first thing i want to talk about is our climate and Health Profile and this is one of the most successful projects to date. This tool kit received several important distunkzsism winner of national snoout of Health Climate change and environmental exposure challenge and also selected for the global publication citys one00printed at the u n Climate Change conference in paris two years ago. Additionally the programs work is recognized by the white house and incorporated into u. S. Climate resilience tool kit dissiminated to communities and policy makers nation wide. The climate and Health Profile links climt projection to Health Outcomes and identifies the populations and locations most susceptible to Climate Change and Health Impacts and it was a standard 40 page government report and what we did is took it and made it into a interactive website. We took all the Climate Science and simplified it so peepical understand it, thury wnt through the Health Impacts and tried to make it place based so put all the neighborhood information in for San Francisco and had a series of 20 to 30 maps so people can understand the localize impact of Climate Change. We also done two detailed assessments. We have done one on vulnerable heat where we created a vulnerable heat index. Also done a similar analysis for flooding looking at the vulnerability to flooding and [no audio] i want to not a lot of work we do is in partnership with different city agencies within the climate and Health Framework on page 7 it listalize the city agencies we work with and work with a lot of Different Community base td organizations where we go and do presentations about the Health Impacts of Climate Change, climate awareness and provide Technical Support and this picture shows maps in the background we created for Community Resilience process. This brings me to the last item i like to discuss today and this is our new report, the climate and Health Adaptation framework that you should have received a copy of. I lelft the part for last because this report is really a continuum of all the work we have done for the last 5 years. The first portion of the report reviewed all the vulnerability assessments i talked about and hemth impacts and climate projections. In the second part of the report, it outlines 8 climate rests identified by the white house under the Obama Administration and for each climate summarize baseline conditions for San Francisco we proposed strategies for consideration which are potential adaptations and interventions to address the climate risk and also proposed indicators to measure the heth heblth impablth for eemp ringe. Last looks at to asays the degree the Health Department is prepared and how to better support climate preparedness activities. I done have time to go through the whole report so will quickly talk about two of the sections. The first section i want to talk about is the proposed strategies for consideration. Our climate and helt team developed a data driven process to identify and prioritize potential adaptation most appropriate for our city. What we started off kooing is a comprehensive literature review to identify the adaptations for 24clusion in the framework and this focus on strategies implemented by department of ubphook health or in par R Partnership and this identified 80 different strategies and talking with specific focus areas within department of pubhook health and this included vector control, food safety, healthy housing and Emergency Preparedness and response. To better understand the information that we retrieved doing the literature review and our key interviews we developed a climate and Health Screening matrix to evaluate the Health Impacts and analyze effectiveness of each adaptation. And so within the report you can see from the slide there is the list of all the different adaptations and interventions but also have a report that documents how we came up with all those and for each bullet point there there is actually a whole page report about the intervention and so as we go back and work with the community, we have all the underlying nrfgz information to help explain the process and solution where work with partners. The last part that i want to highlight from the report is surveys we administered to Public Health division and also San Francisco Health Network directors to better understand management perspective on Climate Change and how they expect Climate Change to not only impact the city but programs they work on and concluded from the survey there is multiple opportunity for the program to assist leadership preparing for climate preparedness within our division. There is also a link to the full survey report. Um, so i have two more slides to finish up. This slide here shows a timeline of next steps for climate and helt adaptation framework so we dont see this framework as a final plan, but it is a starting point to have conversations with communities and city stakeholders of how to best adapt to Climate Change. Now we are in the process of finalizing Community Outreach strategy to get feedback from communities and community organizations. Once we finalize the outreach strategy we will begin conducting stakeholder outreach. During the time period we plan to form a Advisory Team and develop process to select different intervention jz adaptations. Towards the end of the process after we develop get a Advisory Team and develop the process and have Community Input we have adaptations to go forward and develop implementitation maintering strategy which includes implementitation plan, communication and evaluation plan. As i talked about in the beginning of the presentation we received funding from the cdc and received our last round offunding in september of 2016 and that is for 5 years so the process will continue throughout that 5 year period. And so, this was the last slide here what next for the program mpt i just talked about funding. This program is federallyfunded and a line item in the budget which is subject to congressional approval so we will monitor the federal budget based on some of the new administrations viewpoints on Climate Change, there is a possibility there will be funding changes. We will work on process of activity for framework. We will finish our education and outreach curriculum and we will try to find ways to expand that curriculum to have people within our Health Department go out and give those presentation and also work with Community Based organizations to train the model. Lastly we continue to work with range of stakeholders which include people within the department of Public Health, city eejss and regional and National Partners to bridge awareness to Health Impact of Climate Change scr look for solutions. Thank you. Thank you. Commissioner pating. Thank you very much for the great report. And saw this when it wasprinted at the Committee Meeting and even better a second time. I was wonder there are two items one is if you can brag about winning the national grant. We are one of two cities. A east coast city has one. We are the west coast. When we originally applied for the funding it was a competitive grant award and like commissioner pating said, two cities received that award so new york and San Francisco and additionally there is 16 states Health Departments that receive that funding too. So, we are one of 18 cities across the nation that have the programs in their Health Department. Yfs in new york, it was 17 degree jz the rats were running in the subways because it was see so cold. The second question i want to ask but see you address it, i wanted to askthis is such wonderful information how can we share this with citizens . I think there is no worse thing to drive people apart that perhaps talking about rowligion and politics but no better thing to bring people together than talking about the weather good and bad so this is something i think you can unit both citizens of San Francisco around common cause in a positive way that the Health Department is lead toog get climate ready. The idea you do Community Intervention and outreach sounds great so interesting hearing how to share this with citizens. Thinking is this theup there with the bike and food safety. Some sort of brand that would put whether and climate readiness led my by the health duapartment assuming we have fund toog do the efts. I wonner your thoughts on the opportunity take advantage of this report putting the Health Department first and sharing it with citizens across the city. Pending your approval on the report we will issue a press release thursday and release to all our National Partners and to the media, but also right now we are in discussion with the City Partners which include the Planning Department, department of environment, the office of recovery and resilience how to best communicate Climate Change. The risk and Health Impact and Long Term Solutions we will need. We are working doing polling and different surveying to better understand the messaging that will resinate most with the public so we well do the outreach and try to do it in a systematic way and citywide way we have one voice using the same language and the same messages. Actionable is planlting a tree or putting sand bagss. Now department of environment hascalled the 50 50100 roots and that is about reducing the contribution to Green House Gas so taking 50 percent of your trips by bus, bike or public transportation. Looking at zero waste and also abouti dont remember all but they have a outline about reduce thg Carbon Footprint. In addition we also know there will be changes to Climate Change. For example the Planning Department is looking how to deal with Sea Level Rise, the port is looking at resiliency of the sea wall. Longer term we may need a big city wide bond to protect from Climate Change, so we are looking at trying to be strategic about this and the best way and we have been meeting since i think september in trying to come up with the communication strategy and still trying to finalize that but think that is important and doing the work and not communicating it well is disservice. Thipg about the schools. I imagine kid in schools are receptable to the science of Global Warming and wealth waechter change and the message as they share it with their parents. Im sure cindy will dethat with the school district. The one thing to note if we know in advance we will be hotter we have protocols in place but Important Information to prepare ourselves for the future particularly for vulnerable population jz how to respond to those knowing they will continue and increase. The information and work that sinda puts as you can see it is i think incredible and also not many departments have this Incredible Team that is looking at this. As you know , this is a very today in the environment that we are in there is not as much support for the Climate Conversation so think as the helts department wehave to continue to be leaders. I know you implementing schooling stations and had a past heat wave. I imagine we will need more interventions like that. Commissioner sanchez. I just think it is a excellent report both in reference how i identify the areas of concern and translate them into what we are doing based on the data and also show projections where you shared a linking the information with agencies involved in some part of the equation so the fact that we have sort of like a integrated collaborative integration system is helpful. Sometimes they do planning and this and that they may not know the effects on seniors or children especially in these old areas where there are things that would trigger increase in respiratory disease and asthma and with the dta we have and data they project pertaining to new housing or modules with gives a valid base there arechanges that could effect a cohort of people that are more vulnerable than anybody elseism slnt report. Thank you very much. Jrsh thank you for your comments. Commissioner chung . Was going to say that i really appreciate the conversation and curious how additional like Public Education could take place because i think that a lot of us if it is not because of the current Climate Change and how it actually effect our food sources, we wouldnt think about that and Nutritional Program and really food scarsty i believe should be part of whault the preparedness needs to include. Part the report that i didnt mention is that we wnt through all the strategic documents the department of Public Health completed such as Health Network plan, looking at the [inaudible] we identified areas within the report that could include climate preparedness language so trying to figure how to work within the Health Department to expand the message which is important. Thank you for mentioning that. I also think as we were discussing Public Education that it would be important not just for children but parents and all who are interested because they are making sure children are in the proper climate being appropriately cared for. It is clear that we have seen these storms come through just recently and has with dramatic effect to various landscapes. So, it would seem that you have got a plan for the coming year. You have potential funding probably funding if that line item doesnt get too looked at by ourcurrent administration in washington. I would think that you are trying to integrate into Department Programs but there are outside agencies that i think im sure your edge koegel programs are probably going reach those, right . Which could include for example the medical and dental societies and hospital consult and things like that in terms of health because after all those are other Health Agencies that would have very similar needs in their own environment that would be just like they are part of Emergency Services and emergency systems and response, this might be something they may be interested in at least hearing and bringing to their attention. I would suggest that you look at our various medical and Health Agencies in the area. I think the healthcare sector is a area that has a lot of opportunity to utilize this information and pass to the patients and practitioners mpt i think it isgood to see how the year has come and get follow up on the progress has been for the areas that youre hoping to intervene in. I love to come back and present on that. Thank you very much and thank your staff. Such a comprehensive report. I know that fsh a lot of information and appreciate your attention. Im glad im sitting higher on the hill. [laughter. I did note to the medical society last night in that if they couldnt come and of course they couldnt come they should look at this presentation on the website that we have. We are happy to send out the press release or report if you have any suggestions or organizations that you like to share with. Thank you. There are no Public Comment requests for that item. We can move to item 10, which is other business. So, do we have any other business from the commissioners or directors that you wish tobring to our attention . We have taken up Current Business today and changes that we will all face in the next few years. Seeing none, we move to the next item. Item 11 is joint Conference Committee report and dr. Chow you will report on february 28 meeting. February 21 the joint committee met with dr. Shan sanchez in attendance with myself and reviewed the new intercycle Monitoring Survey results which were very positive and we were looking also at the score board and quality measures and how well our hospitals is doing in many measures and where they had challenges and several othersment we will continue to monitor that on a quarterly basis and as dr. Eric had reset the parameters for monitors for 2017 so we will follow that. We also were following the standard reports on quality minutes in which the hospital is now going to combine its quality consal with its patient improvement activity committees to maximize time and effort in a joint meeting of both administration and medical staff personnel. We also received the Regulatory Affairs status report. There were in fact recent surveys to which the hospital performed outstaning. Recent was the Long Term Care survey and also received a 32 e year relicense from the state so those were again just the last months reviews that we had at the hospital. We also rb reviewed the Patient Care Services report. We are monitoring the diversion rates and looking for solutions to the historic highs that have been occurring at the general. We received the rn hiring vacancy report online and foin to fill the vacancies and received the staff report for credentialally Clinical Service rules and regulations, policy procedures and Reference Lab tores that were required to approve yearly. In closed session we also approved the credentials report from the medical staff and the pips minutes. Dont know that dr. Sanchez had any other comments. Otherwise xhauments comments from the commission and if not moouv to the next item. Item 12 is Committee Agenda setting. I believe you have gautd gotten the most updated calendar we have. Post ponement of election to april 4. Okay. I believe we are at item 13, which is a motion for adjournment is in order. So moved. Okay. All in favor say of adjournment please say aye. Aye. Opposed . The meetic is now adjourned. Thank you. [meeting adjourned]. [gavel] good morning. Good morning ladies and gentlemen, i would like to welcome you to the regular meeting of the budget and finance committee. I am supervisor malia cohen, chairperson of this committee. To my right is the vice chair supervisor norman yee and to his right is supervisor tangand i would like to thank our friends up at sfgtv that are assisting