dallas medical journal

v o l u m e 9 8 • n u m b e r 1 0 • o c t o b e r 2 0 1 2

West Ni le V i r u s

I n t h i s i s s u e :

President’s Page - Anatomy of a Crisis

Annual Medical Student Dinner - Photos from the event

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About the Cover PhotoDCMS President Richard W. Snyder II, MD, speaks with a reporter after a press conference about the success of aerial spraying against West Nile Virus.

183 President’s Page “Dr. Snyder, we have a problem.” Anatomy of a Crisis

188 Committee Answers the Call

John Carlo, MD

190 37th Annual Medical Student Dinner Photos from the event

194 Election Preview Second verse, same as the first.

Could be better; could be worse.

199 CMS Audits Meaningful Use

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Dallas County Medical SocietyPO Box 4680, Dallas, TX 75208-0680Phone: 214-948-3622, FAX: 214-946-5805www.dallas-cms.orgEmail: [email protected]

DCMS Communications CommitteeRoger S. Khetan, MD ............................................. ChairRobert Beard, MD Gene Beisert, MDSuzanne Corrigan, MDSeemal R. Desai, MDDaniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MDC. Turner Lewis III, MDDavid Scott Miller, MD

DCMS Board of DirectorsRichard W. Snyder II, MD ................................. PresidentCynthia Sherry, MD .................................President-ElectJeffrey E. Janis, MD .........................Secretary/TreasurerShelton G. Hopkins, MD ......... Immediate Past PresidentMark A. Casanova, MDWendy Chung, MDR. Garret Cynar, MDSarah L. Helfand, MDMichael R. Hicks, MDRainer A. Khetan, MDTodd A. Pollock, MDKim Rice, MDChristian Royer, MD

DCMS StaffMichael J. Darrouzet .................. Chief Executive OfficerLauren N. Cowling ............................... Managing EditorMary Katherine Allen ..........................Advertising Sales

Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish leg-islative advertising in the DMJ: Michael J. Darrouzet, Ex-ecutive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.

Dallas Medical Journal(ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

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President’s Page

Sunday morning, Aug. 5It was with these words from Connie Webster, the DCMS

senior VP of operations, on my cell phone early on a peaceful Sunday morning that the course of my life was dramatically changed over the next 4 weeks. This was the phone call by which I was alerted that we had a serious problem in Dallas County with West Nile Virus and that the medical society may have to become involved.

WNV hardly was on my radar screen at that time, with my knowledge of the disorder mainly derived from what I had learned from the media and informal buzz in the doctor’s lounge. I knew we had experienced an unusual number of cases at Medical City, but I hadn’t yet realized the gravity of the situation on a regional basis. WNV rarely has cardiac involvement, so it did not play a role in my cardiology practice. But all of that was about to change.

Connie was calling to advise me that John Carlo, MD, chairman of the DCMS Community Emergency Response Committee, had called an emergency telephone conference for that night to discuss the escalating WNV epidemic. This meeting was triggered by a letter that was unanimously signed over the weekend by an informal committee of 13 infectious disease physicians who were calling for the immediate implementation of aerial insecticide spraying. This group, representing all major hospital systems in Dallas County, would meet on an informal basis whenever an emergent infectious threat manifested, such as H1N1. Following the initial fatality on July 13 and the alarming number of reported cases so early in the mosquito season, the physicians decided it was time to reactivate their informal group and meet weekly, at the Dallas County Health and Human Services Department to discuss epidemiology, mosquito control and best practices. At its July 27 meeting, the group discussed aerial spraying of insecticides and by its next meeting on Aug. 3, the number of human cases and fatalities of West Nile disease had jumped alarmingly, surpassing the previous record in 2006. (Dallas County had 104 total cases and four deaths for a full season in 2006 and we were only a little more than halfway through the 2012 season.) This is even more startling when one remembers that we had zero human cases in 2010, and just two in 2011. The trajectory of the cases was foreshadowing an historic epidemic that could easily double, and possibly set a record for an urban area in North America.

Clearly, full measures needed to be considered, including aerial spraying as called for in the Centers for Disease Control and Prevention guidelines for a Level 5 WNV outbreak (the highest-multiple human cases). Because aerial spraying had not been employed in Dallas County since the St. Louis encephalitis epidemic in 1966, the ID committee decided to vote on the measure and agreed 13–0 to support immediate aerial spraying. The physicians then generated a letter directed to DCHHS. Knowing this would be a tough, controversial decision for the DCHHS to make for Dallas County residents, it was felt that support from the full DCMS membership would be helpful.

Several members of the informal ID group also sat on the CERC and alerted the chairman, Dr. Carlo, of the recommendation that was circulating for signatures over the weekend and asked for assistance. The epidemic was magnifying swiftly, so time was crucial.

Sunday evening, Aug. 5

The call for the emergency telephone conference of the CERC was organized for that same

Sunday at 7 p.m. We all received texts early Sunday morning alerting us to the need for this meeting and that we would be e-mailed the relevant epidemiology info, scientific papers and signed recommendation from the ID group. The meeting lasted roughly 75 minutes and we thoroughly vetted all options, benefits, risks, and consequences. The CERC by design is made up of senior and experienced physician leaders of all the major hospitals in Dallas County in order to decide how to best respond to a countywide medical emergency such as a hurricane, dirty-bomb attack or H1N1 outbreak. I participated on the call in my role as DCMS president as a nonvoting committee member.

This meeting also resulted in a 13–0 recommendation for immediate aerial spraying. The committee felt that the widespread aerial spraying option, as opposed to targeted truck-based spraying of the same insecticide, clearly was more efficacious and safe for the epidemic we were experiencing.

Monday, Aug. 6129 cases, seventh fatality reported

The CERC recommendation was e-mailed to the DCMS board of directors, with all the relevant guidelines and scientific papers for consideration, as our bylaws require. The board also voted unanimously for this recommendation. A letter was drafted that afternoon to Christopher Perkins, DO, the DCHHS health authority, and signed by myself and Dr. Carlo, as chairman of the CERC on behalf of DCMS, supporting a decision for immediate aerial spraying should Dr. Perkins make that call. To summarize, within 72 hours, 38 DCMS physicians at varying levels of expertise and leadership had reviewed the recommendation, all the relevant epidemiology, guidelines and supporting scientific papers, and had come to the same conclusion. To get 38 physicians to agree unanimously on anything is pretty spectacular; it is more typical that if you have 10 physicians, you’ll get 12 opinions.

The letter was e-mailed to Dr. Perkins and Zachary Thompson, DCHHS director, that afternoon, with copies e-mailed later that afternoon and evening to the Dallas County Commissioners Court, Dallas City Council and Dallas mayor. (A copy of the ID group’s letter and the letter from DCMS are on the WNV section of the DCMS Web site at www.dallas-cms.org.)

“Dr. Snyder, we have a problem....”Anatomy of a Crisis

Wednesday, June 20First reported case of West Nile Virus in Dallas County for 2012

Monday, July 910 total cases

Friday, July 1314 cases, first fatality reported

Thursday, July 1927 cases, second fatality reported

Monday, July 2336 cases

Friday, July 2782 cases, third fatality reported

Monday, July 3094 cases, fourth and fifth fatalities reported

Friday, Aug. 3123 cases, sixth fatality reported

Richard W. Snyder II, MD

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President’s PageTuesday, Aug. 7 142 cases, eighth fatality reported

At the Commissioners Court regular Tuesday morning meeting, the WNV situation and our letter recommending immediate implementation of aerial spraying were reviewed. In our letter, we had offered to be present at the meeting to answer questions, but the court declined our offer. The court then dismissed the physicians’ recommendation to immediately begin aerial spraying. Several commissioners noted that although the county had the option of aerial spraying, they wanted to continue the current targeted truck-based spraying strategy to completion. During the meeting, Commissioner John Wiley Price referred to DCMS physicians as “alarmist,” and Thompson said DCMS was “Monday morning quarterbacking.”

Almost immediately the media inundated DCMS with requests for interviews regarding our letter. WFAA had a camera team at my office by noon for an interview. I participated in a live interview that night during the 9:00 newscast on the Fox affiliate. Additionally, Dr. Carlo and Mark Casanova, MD, a CERC member, did on-camera interviews on NBC, CBS and Univision to explain why we made the recommendation. We were contacted by virtually every media outlet in the region, as well as numerous national print and television media outlets. During the crisis we used social media such as Facebook, the DCMS Web site, and Twitter to get our message out. Dallas Mayor Mike Rawlings even re-tweeted us on several occasions. I cannot tell you how many cell phone numbers of reporters I have collected in my smartphone contact list, so intense was the media attention of the role of DCMS in this crisis.

Wednesday, Aug. 8162 cases, ninth fatality reported

County Judge Clay Jenkins called me and requested that I attend a meeting of experts he was assembling to discuss the WNV situation in Dallas on Friday, Aug. 10. DCHHS experts, the Texas Department of State Health Services commissioner, a county commissioner, the CDC’s top entomologist, and US Department of Homeland Security and FEMA representatives would be among the attendees. Judge Jenkins said I could bring a draftee to help represent DCMS, so I brought the smartest ID guy I know, Dr. Jim Luby. Jim was head of the ID Department at UTSW for 22 years and the guy who authored the original ID letter to the DCHHS department (and later sent to the Commissioners Court) that called for aerial spraying. Dr. Luby additionally was a chief resident at Parkland in 1966, the last time Dallas sprayed for mosquitoes from the air. He has written extensively about that experience and I knew he would be the right choice. (Jerry Jones — now that is how you make a draft pick!)

Thursday, Aug. 9175 cases

Events started to happen quickly, almost like a blur. The recent string of fatalities and daily increase in total cases were haunting. Judge Jenkins declared a public health emergency for Dallas County.

Friday afternoon, Aug. 10181 cases The judge’s panel of 18 experts met for 2 ½ hours to discuss the WNV epidemic. Dallas County residents can be proud of the way Judge Jenkins conducted this meeting. Except for yours truly, he could not have assembled a more knowledgeable, experienced group of experts to dissect the data and science, and to weigh in on this decision. I brought with me a stack of scientific papers, studies and guidelines about 5 inches thick that I had studied like a monk in preparation for this meeting.

I proudly placed them on the conference table and tapped the papers as I spoke. The state’s health commissioner, David Lakey, MD, had a taller stack. (I’m still trying to figure out to whom I can request some CME for all the research I did on this subject.)

The judge was thoroughly prepared and asked tough questions, almost like an inquisition. We then asked the tough questions of each other. The process was comprehensive, methodical, extensive, thorough, and insightful. And it was based on science and data. Dr. Luby was spectacular. At the end of the meeting, the judge thanked us all for our input and opinions, and said he would make a decision soon about aerial spraying. In Texas, the county judge is the most senior Homeland Security official and has the power in a declared public health emergency to authorize an action on behalf of the county. As Dr. Luby and I departed, we traversed a gauntlet of reporters and responded to a myriad of questions.

A little more than an hour later, Judge Jenkins made The Decision. He called an impromptu press conference to make the announcement, just as I had returned to DCMS headquarters. We all watched the events transpire live on TV with the same level of anxiety and expectations reminiscent of the recent Supreme Court decision on health system reform. Then the moment we all were waiting for: the judge authorized the implementation of aerial spraying. At that point, we (DCMS) felt that our role in the saga had ended.

How naïve.

Friday evening, Aug. 10About 6 p.m., the judge called me on my cell and thanked

me for the Society’s contribution to the process and the help in making a decision. He had another question: Did I think the residents of the county would be prepared for aerial spraying by Tuesday? I paused, thought about that serious, sober question for what seemed like an eternity, and responded with my typical insightful answer: “I don’t know.” I suggested that I try to identify the area in the country with the most experience with aerial spraying, and see if I could learn from them and borrow some best practices. That is, after all, what we physicians do — borrow from the experiences of others (good experience comes from bad experience).

At about 8 p.m., before I had a chance to start my on-line research, a staffer from Congressman Pete Sessions’ office called to ask that I attend a 9 p.m. press conference in University Park. The mayor of UP was expected to announce, in the wake of Judge Jenkins’ decision, that the Park Cities were going to ask the County to be aerially sprayed ASAP because they were experiencing such a high concentration of human cases of WNV. At the press conference, the congressman was going to stand in solidarity with the mayor, Judge Jenkins and other city officials supporting this request. Politics and party affiliation evaporates, as it should, when a crisis like this threatens the community. The officials wanted DCMS standing with them supporting this decision and available to answer questions about our unanimous recommendation. The press conference went surprisingly well, with only one reporter asking only one question about the announcement. This community clearly did not have to be sold on the wisdom of aerial spraying.

The weekend, Aug. 11–12

I researched the regions of the country with the most successful mosquito abatement programs and spoke with experts around the country. I learned from these leaders and from Google that Sacramento has the most experience confronting mosquitoes and WNV. The city has been aerially spraying for WNV every year since 2005 (except in 2009) before human illness arises, in response to infection rates in mosquitoes. In Sacramento, the


Sacramento Yolo Mosquito Vector Control District (SYMVCD) is a separate government entity that has directed all aspects of mosquito abatement in Sacramento and Yolo counties since 1946. The district’s Web site and published scientific papers report that it has sprayed aerially for WNV the equivalent of several million people in a dense urban area (Sacramento) with no significant human, environmental, wildlife, or legal consequences over a 7-year period since 2005. And if there ever is, shall we say, “an environmentally sensitive” state, it is California. I wanted to know their best practices and secrets, so I e-mailed and left a voice message on a contact phone number listed on the SYMVCD’s elaborate Web site (www.fightthebite.net).

While I waited for a response, Judge Jenkins began to forward me most of the e-mails he was receiving from concerned citizens about the prospects of aerial spraying. He almost overloaded my e-mail inbox, there were so many. He sent at least 60 of them that weekend alone. I forwarded them all to Michael Darrouzet, the CEO at DCMS. We felt it would be helpful if we categorized the e-mails, and create responses in the form of an FAQ section on the DCMS Web site. DCMS created a fairly comprehensive subsite on the home page called West Nile Virus Resources (www.dallas-cms.org/emerg_response.cfm). We also posted relevant guidelines, scientific papers, DCMS letters and statements, and internet resource links such as to the CDC and EPA, to help alleviate any fears. The Web site also contains a moving and informative video with DCMS Past President Don Read, MD, giving his account as a WNV survivor. We updated the Web site when the judge forwarded unique questions or when we discovered new scientific papers over the next several weeks. Wait a minute … did I say, “we”? This herculean task was performed by Dr. Carlo and many on the DCMS staff, including Connie Webster, Lauren Cowling, Deanna Wooten, and Tracy Casto. They helped defuse some of the anxiety in the community by presenting the science and data in one easily searchable location. Monday, Aug. 13190 cases

I received a call from the SYMVCD public relations director Luz Rodriquez. After just a few minutes, I realized we had hit the motherload! Sacramento offered a wealth of experience and information combatting mosquitoes. Having all the guidelines, scientific papers and expert opinion is great, but real-world experience is priceless! I arranged to have a telephone conference that afternoon with Judge Jenkins’ staff and the folks in Sacramento, including the SYMVCD manager, David Brown. He and the judge became my newest best friends. In fact over the ensuing three weeks, I communicated with both of these gentlemen about WNV several times a day. I think my wife was beginning to suspect I was going through a midlife crisis or had joined a secret society, so frequently were we strategizing on the phone. Later that day, the judge announced that aerial spraying would commence on Thursday, Aug. 16.

Tuesday, Aug. 14207 cases, 10th fatality reported

This was our day in Commissioners Court. WNV was squarely on the agenda because of the divided and vocal opinions about the wisdom of aerial vs truck-based spraying. Thirteen people had registered to speak, mostly against aerial spraying.

Dr. Read, Dr. Luby and I testified for DCMS, and Dr. Carlo was available to answer questions. Passionate presentations were made on both sides of the argument, but no positions seemed swayed. Later that day, DCMS issued a second press release reaffirming our concern about the situation and our recommendation for immediate implementation of aerial

spraying. The transcripts of our testimonies and the press release are on the DCMS Web site.

Thursday, Aug. 16230 cases

Finally, the day aerial spraying was to commence. Eleven cities in Dallas County had opted in for this first round of aerial spraying. My day started with a series of scheduled and impromptu call-in TV and radio interviews beginning at 5:30 a.m. The reporters, despite having submitted a list of questions prior to the interviews, simply couldn’t help themselves and led provocatively with the unannounced ”vindication” question. I did my best to keep them focused on what mattered: getting the county safely out of this crisis. For the remainder of the day I had kept my schedule light, not sure what to expect.As I was soon to find out, my instincts were right and that decision served me well.

At about 11 a.m., I received a text to call the judge “stat.” When I immediately called back, he asked if I were seeing patients, and I replied I was about finished with my last morning appointment. He said that in about 15 minutes, he was meeting with most of the mayors in Dallas County, and they were nervous about the prospects of aerial spraying. He said he needed me by his side because rumors of an injunction and temporary restraining order were circulating that could halt the aerial spraying scheduled for that night. The judge said he needed the support of the medical society to reassure the mayors that aerial spraying was safe. If all the mayors agreed to declare their cities as under public health emergencies, they legally could circumvent any court challenge. I quickly finished with my last patient and, still in scrubs, made a bee-line to the county administration building downtown.

Upon my arrival to a standing-room-only conference room, the judge broke off his comments and asked that I explain the DCMS recommendation, how we came to that conclusion, and what I had learned from the Sacramento experience. I spoke for about 15 minutes and answered questions the best I could. Most, if not all, of the mayors must have signed the emergency declaration because the injunction was not invoked. Throughout the day we heard rumors and radio reports that the air campaign was cycling between being on, and then off, for various reasons. At 4 p.m. I participated in a one-hour radio call-in show/debate on KERA that included the mayor of Dallas and Judge Jenkins. At that point we were guardedly optimistic, but the threat of a temporary restraining order remained.

At about 10 p.m., the judge called my cell and left a voice message: “Rick, I saw it with my own eyes — the planes just took off. Thanks for the Society’s help!” Again, I thought it was “mission accomplished.”

Monday, Aug. 20

But wait! There’s more?In Texas, cities operate under “home rule.” So, not only does

the county have to offer assistance in terms of resources to the community, each city has to agree to accept them. So, each city had to decide whether to be aerially sprayed. Many were having emergency city council meetings to decide the issue, and some had not decided by the time the first round of spraying was to begin. My reward for doing such a good job of presenting to the mayors as a whole on Aug. 13 was to be invited to speak to some city councils and officials individually.

At the request of the mayor, I spoke to the Wilmer City Council. After my presentation, the council voted unanimously in favor of aerial spraying.

As I drove home, I phoned the judge to give him the good news. He was at the Dallas Executive Airport watching the planes take off to start that night’s spraying missions. The first

President’s Page

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President’s Pageround of spraying missions had to be truncated and staggered over five nights instead of the originally intended two because of thunderstorms on consecutive nights. The judge was at the airport every night the planes sprayed Dallas County, almost like a nervous parent chaperoning his teenage kids, at the ready in case any untoward events took place. He invited me to join him. Over the next 2 hours, we had a grand time watching the planes take off, land and refuel. We even chatted with David Brown from Sacramento as we enjoyed the evening under the stars. At the judge’s behest, I joined his kids, mother and staffers in spraying with DEET at regular intervals.

Waiting, Aug. 21–Aug. 30

A second round of spraying occurred, this time over the intended two-night plan in a patchwork fashion to cover those municipalities that opted in later.

Over the next 10 days, we waited anxiously for signs that the spraying was having positive or negative effects. The judge asked me to contact local EDs informally to see if any upticks in symptoms that could be attributed to aerial pesticides were manifesting. The answer at my hospital, Medical City, was no. Although the “research” was informal and not scientific, it was at least something and was reassuring. What the EDs had noticed, though, was a significant increase in people presenting to the ED wanting to be tested for West Nile Virus.

While we waited, the judge and I communicated almost daily and discussed strategies of how the region should learn from this experience and plan for the future. We discussed the idea of a mosquito abatement district for the region, similar to SYMVCD, and how such an organization might better survey and respond to this type of crisis.

Wednesday, Aug. 22

CDC officials briefed the White House and Homeland Security about the WNV epidemic, with emphasis on Dallas. Our medical society was mentioned as having played a supportive role in the decision-making process.

Friday, Aug. 24

JAMA ran an article authored by our own Dr. Robert Haley characterizing WNV and detailing the impact of the 2012 epidemic across the country.

I also got a call from the judge, who passed along a preliminary assessment from the CDC that the aerial campaign had better-than-expected results. He said the CDC had indicated how impressed it was with the speed with which the judge and mayors decided to spray aerially. The CDC said most locally elected bodies need 3–4 weeks before a decision is reached; the judge attributed the swiftness of the decision to a large degree to DCMS.

Saturday, Aug. 25

Michael and I advised neighboring medical societies of DCMS’ decision to recommend to our local elected officials the immediate implementation of aerial spraying. On Aug. 28 Denton County Medical Society issued a press release recommending aerial spraying for its community.

Monday, Aug. 27

By this time I am so tired of talking about mosquitoes and Culex pipiens quinquefasciatus (say that one10 times fast!) that I almost want to scream.

Thursday, Aug. 30

The first big outcomes milestone arrived. The county, City of Dallas and CDC held a press conference at which the CDC released findings from the postspray trap survey detailing the

effects of the aerial campaign on the mosquito population. I represented DCMS during the Q&A session. The result was an astonishing 93 percent reduction of mosquitoes capable of carrying the West Nile Virus. In fact, data showed an increase in mosquitoes in areas not aerially sprayed. We were stunned. We had not expected such good news. This was accomplished with seemingly no significant adverse affects on the human population, wildlife or the environment. The judge thanked those who participated in the campaign: “I want to publicly thank those without whom the aerial campaign would not have been successful ... the Dallas County Medical Society … whose compelling and fact-based analysis was instrumental in the decision.”

The judge afterward treated his staff, the CDC team and yours truly to a celebratory refreshment at a local restaurant.

Early September

But those results were only surrogates for the real goal: halting the human impact of the disease. About a week later, our hopes were confirmed with a dramatic reduction in the reporting of human cases in Dallas County in those areas that were aerially sprayed (after the 15-day incubation period had been considered). This was the news we had been waiting for. And, with it, all the time and effort of dozens of individuals from DCMS who put in countless hours every day contributing to this effort immediately seemed worthwhile.

Kudos and Remembrances

DCMS has a long history of leadership during public health crises, including the polio and St. Louis encephalitis epidemics in the 1950s and ‘60s. The society’s response to the WNV crisis this year echoed those efforts. Your county medical society is proud to have played a role. We hope you will visit the DCMS Web site and learn more about WNV.

Thanks to the DCMS staff for being equal to the challenge. I particularly want to recognize Michael and Connie for their efforts. Michael claims he keeps every e-mail in an electronic file system. If so, his WNV file counts e-mails in the hundreds, if not thousands. Also, Tracy Casto and Lauren Cowling played a BIG role in coordinating communications with the judge’s office and the media, and with our messaging and education efforts on the Web site. They all spent several hours a day over the last several weeks, including nights and weekends, promoting this campaign. They not only tolerated my demands for the role that the society should play, but they embraced it with passion.

Thanks to the dozens of DCMS physicians who upheld the mission and goals of the society during this crisis:

“To advocate for physicians and their patients, to promote a healthy community … to establish the medical society as the definitive source of healthcare information in North Texas.”

This crisis has taught us that the ideal of the physician advocate is alive and well in Dallas County. Remember, regarding the health care our patients receive, we physicians have as much impact in legislative chambers and board rooms (and, in this case, a Commissioners Court) as in exam rooms and operating rooms. As clinicians we treat one patient at a time, but as physician advocates, we have the opportunity to treat everyone, even a whole county, at once!

Follow Dr. Snyder on Twitter @DCMSPres!


Summer 2012 was the worst season for human West Nile Virus infections in Dallas County since the virus appeared in our area in 20031. It will be marked as a year that environmental control measures included aerial insecticide spraying — a measure not undertaken in Dallas since the St. Louis encephalitis outbreak of 1966. Other areas in the United States experienced a resurgence of cases, but North Texas appears to have been the epicenter of activity. Although reasons for the severity of the outbreak here may never fully be elucidated, possible explanations include weather patterns and more highly susceptible bird populations as a result of the extremely low activity here the preceding two years.

Physician leaders from Dallas County Medical Society, working as part of the DCMS Community Emergency Response Committee, were integral to the response of this year’s outbreak. This committee was an important force to leverage physician concern about the outbreak and provided the response strategy on aerial spraying which helped guide the Dallas County government’s policy regarding this action.

For the Community Emergency Response Committee, this call to public service was not new. The committee was formed in 2006 to provide a mechanism for organizing physician volunteers

during a public health emergency. This need was recognized when the medical society mobilized physicians to provide medical care for individuals displaced during hurricanes Katrina and Rita. The committee was formed also to assist the Dallas County Health Authority by providing rapid access to local physician subject matter experts during times of public health crises, including physicians with expertise in emergency medicine, pediatrics, critical care, infectious disease, internal medicine, and family medicine.

In 2008, the Community Emergency Response Committee helped organize physician volunteers to support the medical clinics for local shelters housing evacuees from hurricanes Ike and Gustav. In 2009, committee members provided vital guidance and support during the early phase of the H1N1 pandemic. Through their input, local school closure decisions were soundly made which were consistent with the epidemic’s severity.

This year, as a result of the increasing trend of human West Nile cases, the Dallas County Health Department’s Epidemiology Division, led by Wendy Chung, MD, began convening weekly meetings with area infectious disease physicians. These physicians included James Luby, MD, an infectious disease physician at UT Southwestern and expert in vector-borne diseases. Dr. Luby, as

by John T. Carlo, MD, MS DCMS Emergency Response Committee chair, former medical director/health authority for Dallas County Health and Human Services, and current program director for the Center for Infectious Disease Research and Policy at the University of Minnesota

Committee Answers the Call

Factors the DCMS Community Emergency Response Committee considered when Recommending Aerial Spraying

• The number of human cases of West Nile Infections reported was significantly higher than what had been reported during prior years for the same time period.

• Prior years’ data on West Nile Infections in Dallas indicated a seasonal pattern with a peak in incidence occurring during August. Thus, the number of cases likely would continue to rise.

• The percentage of mosquito pools testing positive for West Nile Virus trapped by city and county mosquito control offices was significantly higher than what had been observed in previous years.

• Under similar conditions in 1966 with the St. Louis

encephalitis outbreak, aerial spraying in Dallas demonstrated significant effectiveness in reducing the risk of mosquito-borne infections.

• Aerial spraying conducted elsewhere in the United States, including areas with similar urban density (Sacramento), demonstrated effectiveness in controlling West Nile Virus infections in mosquito populations.

• A number of peer-reviewed studies indicated that aerial spraying was safe, and, when completed correctly, causes minimal environmental impact and has minimal risk to humans.


a member of the Community Emergency Response Committee, proposed an immediate convening of the committee. He worked with local infectious disease physicians to draft a letter outlining their concerns about the outbreak and suggesting that targeted aerial spraying was indicated.

After rapidly convening by conference call and reviewing epidemiological information and trends, the Community Emergency Response Committee unanimously recommended that additional control measures, including aerial spraying, immediately be undertaken. This recommendation resulted in creation of a letter sent to Christopher Perkins, DO, Dallas County health authority; and Zachary Thompson, Dallas County Department of Health and Human Services director. The letter also was discussed with them by phone, and then forwarded to area elected officials and other government emergency management agencies.

Shortly after receipt of the two physician recommendation letters, and in conjunction with advisers from the Texas Department of State Health Services and the US Centers for Disease Control and Prevention, on Friday, Aug. 9, 2012, Dallas County Judge Clay Jenkins declared a public health emergency. By making this declaration, the judge is granted broad powers under Texas law to carry out necessary measures to protect the public’s health and safety. The reason for this declaration was clear — it allowed aerial spraying to be conducted in Dallas County without further deliberation. The declaration also allowed for the use of state emergency funds to pay for spraying operations as opposed to using city and county funds. During the commissioners court meeting on Tuesday, Aug. 14, committee members including Drs. James Luby and Don Read, as well as DCMS President Richard W. Snyder II, MD, gave

important testimony, and provided the county judge with scientific data, research and guidance for responding to constituent concerns. After cities within Dallas County decided to participate in the aerial spraying, operations began across Dallas County, fewer than 2 weeks after the Emergency Response Committee initial meeting.

A number of factors justified aerial spraying (see preceding table). The committee found that evidence indicated that the outbreak was evolving to be one of the most severe in Texas’ history. Additionally, the traditional methods of control and prevention, including urging individuals to use insect repellent, remove standing water on their property, use larvicide, and to have cities spray insecticide from trucks, were not sufficiently dampening the outbreak. Because the outbreak was occurring over a large area, aerial spraying appeared to be the most effective option for rapidly curtailing the West Nile transmission cycle from mosquitos.

This year’s effort, as well as prior calls to action, demonstrates the important role of the DCMS Community Emergency Response Committee for DCMS members and the greater Dallas community. During public health emergencies, leaders often are called upon to make difficult decisions that impact the entire community. By providing a forum for discussion and rapid communication of physicians’ observations and expertise, the committee members as part of the DCMS leadership will continue to assist community leaders who must make these difficult decisions.

1 The Dallas County Health Authority is a physician appointed by the Dallas County Commissioners Court to administer state and local laws relating to public health.

Community Emergency Response Committee Members

John T. Carlo, MD, ChairTerry D. Allen, MDMark A. Casanova, MDWendy M. Chung, MDCristie Columbus, MD

Robert L. Fine, MDRaymond L. Fowler, MDSarah L. Helfand, MDStephen A. Landers, MDJames P. Luby, MD

Mark S. Mlcak, MDCarol S. North, MDDon R. Read, MDConnie Webster, Staff


37 t h Annual Medical Student DinnerThe 37th Annual Medical Student Dinner was a great success. Some 253 students from both

UTSW and Baylor Dallas campus of Texas A&M Health Science Center College of Medicine joined 69 DCMS member physicians and their guests at the Doubletree Campbell Center for a cocktail hour, dinner and discussion. The DCMS and TMA presidents and the AMA president-elect participated in a question-and-answer session for the students, and shared their experiences from medical school and their careers.

CaptionDrs. Stephen Ozanne, Rhonda Walton and Jim Walton

CaptionDuane Barnett, MD, and wife, Joan

CaptionDean Sherry with Drs. Cynthia Sherry and Eugene Hunt

Roberta Read, Drs. Don Read and Cliff Moy, Kaki Hopkins, and Elizabeth Gunby

Caption Randall Rosenblatt, MD, hosts a table of students.


CaptionDrs. Wayne Gossard and Fred Ciarochi CaptionVernil Mitchell, Vijaya Vemula, and Drs. Narasimharao Vemula, Charles Mitchell and Robert Gunby

CaptionJules Monier, MD, chats with students at his table.CaptionPhil Huber, MD, and wife, Lynne, with student

CaptionStudents and Shelton Hopkins, MD

CaptionJoseph Schneider, MD, and wife, Katharine, with students

DCMS President Richard W. Snyder II, MD; AMA President Ardis Hoven, MD; and TMA President Michael Speer, MD

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Entertainment includes: Dallas School of Rock Band, green-screen photography, 3-shot pool and basketball, face painting, kids' craft station, balloon artists, and goodie bags.

This is a great evening to enjoy with your family and to network with your physician colleagues.

RSVP BY FRIDAY, OCT. 26 Fax this form to 214.946.5805, or call Cara Jaggers at 214.413.1423,

or e-mail RSVP information to [email protected].

The only cost is $7 to park your tour bus.Dinner is FREE, thanks to our event sponsors: DCMS Circle of Friends, TMLT, TMAIT,

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YOU ARE INVITED TO THE 2012DCMS MEMBER ROUNDUP

by Tracy Casto, director of public affairs and advocacy


With the US District Court of the District of Columbia overturning the Texas Legislature’s maps, 2013 again will be a redistricting session for lawmakers. The central conflict was the changes made to the Senate district map. Those who challenged the map argued that lawmakers violated the Voting Rights Act by dividing minority neighborhoods and adding them to other Senate districts, which diluted their ability to influence elections. The three-judge DC federal panel agreed, ruling that the state had splintered those cohesive minority neighborhoods. The court opined that the maps the Legislature had adopted were regressive because when the number of congressional districts was increased from 32 to 36, the percentage of minority ability districts was not maintained, thus decreasing minority influence.

This opinion is relating to the legislatively adopted maps — NOT the interim maps issued by the Western US District Court in San Antonio. The DC district court can only approve or disapprove the legislatively adopted maps; they cannot adopt new maps. The Western US District Court can determine whether the interim map resolved the issues in the DC district court’s decision as to whether the interim map could be adopted as the final map. However, Attorney General Greg Abbott has said he will appeal the DC district court’s decision to the US Supreme Court.

The November general election will take place under the boundaries of the maps now in place. Negotiations over the interim maps led to an agreement among the parties to reset the boundaries to where they existed during the previous decade.

Texas sales tax revenue up for yearLawmakers should have a more pleasant session

than anticipated, thanks to the recent uptick in sales

tax revenue (and not all a result of the sales tax we now pay to Amazon.com). Texas closed out its 2012 fiscal year at the end of August with its most important source of revenue up 12.6 percent from FY 2011.

Texas generated about $1.6 billion more in sales tax than Comptroller Susan Combs had projected. All told, the state is about $3.7 billion ahead of Combs’ estimate when looking at sources of tax revenue.

For the month of August (reflecting sales transactions in July), state sales tax collections were up 18.5 percent compared to August 2011. The oil and gas industry continued to be a major driver of the hefty tax collections as well as the strong retail performance, Combs noted.

HealthPAC’s candidate ready to workYour HealthPAC board members did yeomen’s work

in determining to endorse Theresa Daniel, a Democrat, in the race to represent the newly drawn District 1 on the Dallas County Commissioners Court. In one take, the board interviewed three Democrat and two Republican candidates prior to the primary election. The board agreed to contribute $500 to each campaign and to make an endorsement after the primary. The board since has contributed an additional $1,000 to Daniel’s campaign. In the general election, she faces Republican Larry Miller.

Miller is a retired Air Force colonel and former district attorney in Hunt County. He was approached by Dallas County Commissioner Mike Cantrell to run. Miller said that the five-member court needs a member who can provide “proven senior leadership.” His top issue is criminal justice.

Daniel has long been active in the Democratic Party and is a former staff member for Congressman Martin Frost. She’s spent 35 years in public service, and now works for the DISD in program evaluation and accountability. She says her experience in looking for best practices will help her develop solutions in her top areas: public health, criminal justice and clean air.

Three Democrats serve on the five-member

Election PreviewSecond verse, same as the first. Could be better; could be worse.


Commissioners Court. One of the two Republicans, Maurine Dickey, is not seeking reelection in District 1. After redistricting, District 1 is 48 percent Hispanic, 27 percent Anglo and 21 percent African-American. District 1 previously was solidly Republican in northern Dallas County.

Daniel received a PhD in public policy and public administration from UT Arlington and earned master’s degrees in public affairs, social work and urban studies.

She is appreciative of HealthPAC’s support and is ready to work with the other commissioners to improve life for Dallas County residents.

“The challenges of the general election and of the position of commissioner are many, but I am excited to take them on,” she says. She has spent her entire life working in the public sector and says she knows the issues that the Commissioners Court should be addressing. “I’ll come to the office ready to work,” she says.

HealthPAC questioned the candidates about Parkland Health & Hospital System and its seven-member board of managers, which the commissioners appoint. Daniel was surprised that more board members don’t have medical backgrounds because they need to know what the physicians, nurses and patients experience at Parkland. She said she would appoint people to the board of managers who have a healthcare background; of the seven members, she would want four physicians. Of the other three members, one should be a consumer, and they should have talents in budgets and hospital start-ups.

In choosing three words to describe herself, she said that she’s fair, inclusive and transparent.

TEXPAC endorses in Dallas races TEXPAC has endorsed 23 Republicans and 12

Democrats in contested races for the Texas House of Representatives in the general election, including several newcomers. When recommending an endorsement to the TEXPAC board of directors, the TEXPAC Candidate Evaluation Committee considers input from the district chairs and the local physician community, reviews of candidate stances on TMA’s issues, and evaluations of potential outcomes of challenged races. The board

was to recommend endorsements after interviewing candidates on Sept. 25. Results will be posted on the DCMS Web site.

District 115TEXPAC has been instrumental in the District 115

race, beginning with candidate interviews almost a year ago. In a four-candidate field, TEXPAC endorsed civil engineer Bennett Ratliff of Coppell in the Republican primary. Support continued when he faced a runoff against Steve Nguyen, an Irving optometrist. A volunteer working the polls for Ratliff during the primary runoff changed some voters’ minds when she told them that their physicians statewide had endorsed Ratliff in that race. They were surprised that the physicians wouldn’t be supporting “Dr. Steve.” But he may have garnered a few votes on a 106-degree day when an ice cream truck bedecked with “Vote for Dr. Steve” gave samples in the parking lot to people who had voted (granted, ice cream was distributed regardless of party ID). Ratliff faces Democrat Mary Clare Fabishak and Libertarian Preston Poulter in November.

District 114This race pits former State Rep. Carol Kent (D-Dallas)

against newcomer Jason Villalba (R-Dallas) in the district previously represented by Republican Will Hartnett, who retired from the House after last session.

To make it to the general election, Villalba defeated two Republicans, including former State Rep. Bill Keffer. With redistricting, the winner will represent the Lake Highlands, East Dallas and Preston Hollow areas. Kent served in the district formerly known as 102 and Keffer served in District 107.

TEXPAC endorsed Kent in the Democratic Primary and Villalba in the Republican Primary.

District 107State Rep. Ken Sheets (R-Grand Prairie) faces former

State Rep. Robert Miklos (D-Mesquite), whose district changed after redistricting.

Critical election dates

“The Elections of 2012—The Movie” has had a long run but is almost to the credits. The show concludes with the general election on Tuesday, Nov. 6.

Eligible Texans who are not registered to vote must register by Oct. 9 to vote in the November election. Check out www.votexas.gov for more info.

Voters did not have to vote in the May 29 primary election or a runoff election to qualify to vote in the general election. Also, voters are not required to vote for the candidate they chose in the primary.

Early voting for the general election runs Monday, Oct. 22, through Friday, Nov. 2. The Dallas County Elections Department Web site has details regarding dates, times and polling places: http://dalcoelections.org/nov62012/EVLocations.htm.

When recommending an endorsement to the TEXPAC board of directors, the TEXPAC Candidate Evaluation Committee considers input from the district chairs and the local physician community, reviews of candidate stances on TMA’s issues, and evaluations of potential outcomes of challenged races.

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The Project Access Dallas Physician Network team has created a contest to encourage peer-to-peer recruitment within the top needed specialties.

PAD Contest Winners

Rosemary McCoy, MD

Project Access Dallas presented De Shawndranique Gray, MD, with an iPad 2 for her participation in PAD. Dr. Gray, an ob/gyn affiliated with Methodist Charlton Medical Center, enthusiastically signed up to see one PAD patient a month. We are so grateful for her service!

Rosemary McCoy, MD, medical director of the Women’s Wellness Center at Medical City Dallas Hospital, generously has volunteered to see Project Access Dallas patients in need of women’s services. In recognition of Dr. McCoy’s donation of time and services, PAD rewarded her with an iPad 2.

Marilyn Haspany, PAD physician network director, and De Shawndranique Gray, MD

Early diagnosis and treatment of HIV

saves money and improves health outcomes.

Routine HIV testing in health care settings is as cost effective as

other screening programs, including type 2 diabetes and breast

cancer mammography.

Learn more at

www.testtexashiv.org

Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/μL) with HIV infection.

HIV Medicine. 2004;5:93-8.

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swdic_BCA Sept11_DMJ_comp.pdf 8/1/2011 4:08:13 PM

Interested in joining?Contact Mary Katherine [email protected] 214.413.1456

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The Centers for Medicare & Medicaid Services is auditing physicians and other healthcare professionals who receive meaningful use incentive payments. CMS is required to audit those attesting to meaningful use, but until this point, the agency only has posted general information about the audits.

CMS says anyone who receives the incentives could be audited and that recipients should retain all sup-porting documentation, whether it is paper or electronic, for six years.

The Garden City, N.Y., accounting firm Figliozzi & Co. is conducting the audits for CMS. The firm is send-ing letters asking for documentation supporting the meaningful use attestation.

Figliozzi seeks four types of data: • Documentation from the Office of the National Coordinator for Health IT showing use of a certified

electronic health record system for meaningful use attestation;

• Information about the method used to report emergency department admissions (for hospitals);

• Documentation that the attestation for the core set of meaningful use criteria was completed; and

• Documentation that the required number of menu set meaningful use objectives was completed.

Physicians and others selected for the audits have two weeks to submit their documentation. The audits are not expected to involve site visits, CMS says.

The Texas regional extension centers were established with federal grants to help physicians with EHR adoption and the meaningful use incentive program. The grants provide subsidies to primary care physi-cians. Specialists also are eligible for REC services, but the services are not subsidized.

For answers about the incentive program and other health information technology needs, contact TMA’s Department of Health Information Technology at (800) 880-5720.

Article also linked here: http://www.texmed.org/Template.aspx?id=25014

CMS Audits Meaningful Use


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Supporting the improvement and distributionof quality health services across Dallas County.YOUR GIFT WILL SUPPORT MULTIPLE PROGRAMS HELPING DALLAS COUNTY RESIDENTS IN NEED.

I WOULD LIKE TO CONTRIBUTE

Donate online at www.active.com/donate/12campaign

Please remove this panel and mail to:DCMS FOUNDATION

P.O. BOX 4680DALLAS, TX 75208

DCMS Foundation is a 501(c)3 charity and can receive tax-deductible donations. Gifts are deductible for federal income tax purposes to the extent allowed by law.

I have enclosed my gift/pledge in the amount of $ (Please make check payable to DCMS Foundation.)

Name:

Billing Address:

City: State: ZIP:

I would like my gift/pledge to be charged to my: Visa MasterCard Discover American Express In the amount of $

Specifically to the Where needed most

I would like my gift/pledge to automatically recur monthly: until I contact you until


Isn't it about time you focused more on medicine,

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What do you get out of SPA Membership? Contracting: SPA reviews

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Operations: The contract

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C r e d e n t i a l i n g : All SPA Contracts include

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Ancillary Services: SPA has

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This helps you to keep your overhead

Find out more about how we can help your practice at www.spa-dallas.com or call 214.346.6623 8150 N. Central Expressway • Suite 1250 • Dallas, TX 75206

PRACTICE MANAGEMENT

FACT: Physicians earn more money per hour in the clinic and the O.R. — practicing the skill of medicine — than they can playing accountant, coder or office manager. Delegation is the key of every successful business enterprise.

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Value: All of

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SPA ad DCMS 9/11.indd 1 9/13/11 12:08:29 PM


Isn't it about time you focused more on medicine,

and less on administrative hassles?

D o you enjoy reading man-

aged care contracts? How

about completing multiple

applications? Do you know if you

are being reimbursed correctly?

Could a physician-operated IPA be

the answer?

What do you get out of SPA Membership? Contracting: SPA reviews

hundreds of pages of legal terms with

the cooperation of the health plan

and presents you with an objective

summary of the terms in a format

which is standardized. Then,

"SPA Compare" allows you

to analyze the fees offered

compared to local Medicare

and to other commercial

plans in a way that is customized

to your practice.

Operations: The contract

summary and SPA Compare may

easily be used by your collections

operation to be sure that you are

being paid properly under the

SPA Contract. SPA maintains

relationships with its contracted

health plans which help you receive

what you are entitled to under the

SPA Contract.

C r e d e n t i a l i n g : All SPA Contracts include

delegated credentialing and

recredentialing. This allows you

to contract with many plans by

completing only one application and

allows you to keep your credentials

updated with many payors through

only one entity.

Ancillary Services: SPA has

group purchasing rates for medical

supplies, medical waste disposal

and other services for SPA members.

This helps you to keep your overhead

Find out more about how we can help your practice at www.spa-dallas.com or call 214.346.6623 8150 N. Central Expressway • Suite 1250 • Dallas, TX 75206

PRACTICE MANAGEMENT

FACT: Physicians earn more money per hour in the clinic and the O.R. — practicing the skill of medicine — than they can playing accountant, coder or office manager. Delegation is the key of every successful business enterprise.

costs low.

Value: All of

these benefits

come from a

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IPA for less than $80 per

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Want to find out more? Call

us at 214-346-6623, or visit us at

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SPA ad DCMS 9/11.indd 1 9/13/11 12:08:29 PM

T h e R e t i r e d P h y s i c i a n s C l u b

(Top left) RPC President Nancy Hitzfelder, MD, opens the meeting. (Top right) Former DCMS executive officer Bob Heath and his wife,Vanita (Bottom left) DCMS Past Presidents Drs. Shelton Hopkins and Fred Ciarochi (Bottom right) Drs. David Alkek and Nancy Hitzfelder

The Retired Physicians Club met Sept. 19 for a presentation on “The Meaning of Life — an Eastern Perspective.”

For more information on RPC, contact [email protected].

Come to where you are wanted.

TEXAS REGIONAL MEDICAL CENTER AT SUNNYVALE JOIN THE CUTTING EDGE OF OPPORTUNITY

OPPORTUNITYIS WHERE

YOU FIND IT.START HERE.

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Contact Administration at 972-892-4404 to open a confidential dialogue.


NTAHP Health Information Exchange Launches

The North Texas Accountable Healthcare Partnership, a 501(c)(3), nonprofit, multistakeholder organization, is the state funded information exchange for North Texas that was pioneered by DCMS. The support of DCMS has been instrumental in the development of the NTAHP HIE. As one of the 12 sanctioned Regional Health Information Exchanges by the State of Texas, the Partnership covers a service area including 13 counties, nearly 12,000 physicians, 137 hospitals, and more than 6.5 million Texans.

The mission of NTAHP is to promote and reward local healthcare clinical performance for the citizens of North Texas that is coordinated, transparent and value-based. The goal of the NTAHP HIE is to allow for the secure electronic movement of health-related patient information among healthcare entities. This type of exchange will allow physicians to connect to multiple disparate healthcare systems, providers and labs without barriers.

For clinicians who practice at multiple hospital systems, this is key. A Health Information Exchange that is Web-based and interoperable with multiple Health Information Systems allows physicians to focus on the practice of medicine and the treatment of patients. Confidence can be gained in the knowledge that patients’ health records can follow them anywhere in the healthcare community, at the point of care, regardless of the healthcare system they are being treated in, thanks to the NTAHP HIE software.

The NTAHP HIE’s services are anticipated for general availability in early October 2012, which will allow physicians to quickly, efficiently and securely look up a patient at the point of care and receive the relevant, real-time information, as well as information from past events. At launch, the NTAHP HIE capabilities will center on the longitudinal patient health record, which includes real-time access to patient demographics, allergies, lab results, radiology reports, medications, problems and procedures, and transcribed documents.

Ultimately, the NTAHP HIE is not another technology project, but rather a clinical tool intended to improve patient care. NTAHP invites you to help make healthcare more transparent, efficient and cost effective for the patients of North Texas.

To learn more, contact the North Texas Accountable Healthcare Partnership at 817.274.6300 or e-mail Jeff Stever at [email protected].

How many times have you been frustrated due to the lack of a patient’s complete health information at the time of treatment? Even more confused about the implications of Meaningful Use Stage 2 and Accountable Care Organizations?

At least 32 million U.S. households own

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Documents

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