Transcripts For SFGTV Health Commission 20240712

Comment . Clerk those of you on the Public Comment line press star, 3, to make a comment on the minutes. Star, 3. All right, no hands raised. So we can move on. President bernal upon review of the minutes, commissioners, a motion to approve. So moved. Second. Clerk i will do roll call vote. [roll call] great, the item passes. Next is the report. Im sorry . Is it okay if i call out . President bernal yes. On the minutes. Clerk okay. So the next item, number 3, the directors report. Good afternoon, commissioners. The director of health, and i will summarize and take any additional questions. Theres a lot going on in the world of Public Health. Some good news, september 9th the Supreme Court upheld proposition c, which will free up hundreds of millions of dollars for funding for homeless services, including a significant amount that will be dedicated to the Behavioral Health services for homeless individuals. So we are looking forward to hearing more on the legal opinion of that. But good news in terms of more resources for Behavioral Health issues where they intersect with people who are experiencing homelessness. And we are currently gathering more information to determine how quickly those funds, if and how quickly those funds will be available. And im happy to report that to the commission when we have that information. With regard to 19, we are continuing on our gradual safer reopening based on the latest data and science. For instance, as of today, we have after opening up a number of places earlier this month, as of today we have indoor activities, including personal grooming services, very limited indoor gym and personal trainer activities, and then we museums may open potentially as soon as september 21st, obviously, with safety guidelines in place. We are also moving forward with school reopenings. Schools that were submitting safety plans and well start with a ksixth grade and a move to middle school and then high school and a gradual reopening. And the team has been working very hard on that. Well cover more covid19 issues in detail further on in the agenda. Good news on the front with regard to h. I. V. We released our h. I. V. Report in 2019, and we achieved a record low of 166 cases of h. I. V. In the city. This is a 19 decrease in new diagnosis since the Previous Year and declines were seen across almost all groups, including among black african americans, people who are on drugs and people experiencing homelessness. There continue to be inequities with in a spike of crimes and of our goal of getting to zero with other h. I. V. Programs. In regard to work in the covid19 pandemic with regard to research, we also were able to collaborate with with u. C. San francisco, the Latino Task Force on covid19, and d. P. H. , and with supervisor Hillary Ronen and the biohub, which conducted testing in a transit hub, at 24th Street Mission plaza, found very high rates of positivity among the latino population at that at that site. Consistent with the findings that we continue to see high inequities of covid19 diagnoses among latinos who constitute 51 of current cases. We are focusing to looking at our prevention and care response, including through increased access to testing. As i previously described we now have mobile popup sites with testing expanding to multiple neighborhoods with high rates of covid19 infection, including the mission, and visitation valley. And i just wanted to share the data that with regard to Contact Tracing and case investigation, 89 of latino cases have been interviewed with more than 90 of contacts interviewed since june. This is actually higher than the overall average. And then in keeping with our isolation and quarantine availability and ensuring that people have opportunities to isolate and quarantine if they cannot do so at home, up 46 of the residents in isolation at home or in hotels have identified as latino. I will stop there and well, actually, theres one other key issue that i do want to highlight in the directors report, which is that we have been working very diligently and in partnership at covid command with our partners at the department of Emergency Management with regard to air quality. And the intersection, obviously, of air quality and hit health, d ensuring that we are sending the messages that communities are being supported where necessary with facial coverings and that staff have the support they need in order to deal with what has been a very challenging couple weeks with regard to air quality. And also as of labor day with heat, unfortunately, given the effects of climate change, this is not the first time that weve had this, and because of covid command were more coordinated in our response than ever before. And other things in the directors report that i dont have time to read through today. Theres a number of press links, that im happy to answer any questions about. Thank you, commissioners. President bernal any comments . Yes, i have folks on the comment line. If you would like to make comment on this line, raise your hand by pressing star, 3, so well know. Give you a few seconds. All right, it looks like theres no comments to this item. President bernal all right. Commissioners, any questions or comments . I dont see any hands raised, but does anyone want to chime in. Clerk commissioner christian raised her hand. Commissioner christian thank you. Director, i wanted to ask very quickly if theres in an ongoing way, if theres any guidance that you can give the department can give to san franciscans about how to protect ourselves from the smoke and chemicals in the air, from the wildfires when we are not able to use the medical grade res re. And were not using them for smoke. Theres so much toxicity in the air and even when we dont smell smoke or when we see smoke, and that, obviously, as the Department Tells us, weakens the pulmonary systems, makes people more vulnerable to covid and to flu and to everything else. So, you know, obviously theres a correlation but we dont have the protective measures that we would like to in order to protect ourselves from that. Given that we cant use the medicalgrade rerespirators, is any guidance that you could give to us how we can fortify our masks, or our cloth masks, anything that we could do traveling to and from work or out by necessity to protect ourselves . Thanks. Thank you, commissioner. We do have guidance, its somewhat complex given the air quality and different populations that are at risk, depending on the air quality. But i can certainly provide you with that link and we can make sure that we get it before this meeting is concluded to share with the commission in terms of exactly what youre asking for. So ill make sure that we get that before the end of this meeting. Commissioner christian thank you. And also just continuing the great work that youre doing about getting information out to the Community Every day. So, thank you so much. Absolutely, thank you, commissioner. President bernal commissioner chow. Commissioner chow yes, i just wanted to make a comment to commend the department and dr. Colfax on the h. I. V. Report. And i understand that were going to hear it in our next meeting, but i didnt think that we should let that go without commending the work thats been done there. Its tremendous. And even though we havent quite gotten to zero, at least for some of us who have been around for a while, this continues to be an amazing trend. And in the face of it getting harder as we get smaller and smaller numbers. So, again, kudos to the department and we really look forward to seeing the report next meeting. Thank you. President bernal commissioners, any other questions or comments . I just have two quickly. Director colfax, first of all, i wanted to second what commissioner chow had said about the h. I. V. Report, its a very Promising Development as we continue to see decreases yearoveryear. And its a testament to the excellent work that the commission and the department has been doing on an ongoing basis. Seeing dr. Buckbinder, Susan Buchbinder on the agenda to speak about our vaccine work reminds me not only of the wonderful work that the department across all areas does, but the additional burdens and the additional stress thats placed both on staff from the executive staff throughout all of our programs to our frontline workers. Can you just sort of characterize how the staff is doing, are they experiencing, you know, fatigue . Are there resources that the commission or support that the commission can offer in order to support them personally as they do their critical work and network . Well, thank you, commissioner bernal and i appreciate the question. I think that as you said this is a marathon. And i think that were in a stage now where were, i dont know, the 10th or 15th mile. And this is where, you know, some of the adrenalin, institution adrenalin, is starting to wear off and people are really, you know, i think that some people are dog tired, to be totally candid. Were digging deep. I think that theres resilience among the d. P. H. Team, and as importantly, and more importantly, the Community Partnerships are in this response. And we are looking at im looking at what can we continue to do and what are some things that may need to be potentially delayed in the Department Just because we have so many Different Things going on. And covid19 is, obviously, paramount in our need to respond. So i think were looking at that. And that hearing that if there are certain components not so much service delivery, because you know, with the board support we are not cutting any services, even though its a challenging budget environment. But other things that can be delayed in response to our covid19 needs. We have hundreds of people working at covid command. All those people have very very busy jobs before they were put into covid command. And they are very busy there as well. But, certainly, i think that the capacity for the department to do everything at the same time is really challenging right now. Again, we are used to working in a scarce in an environment of scarcity and thats sort of where Public Health has been for many decades. So i think that we can be responsive and continue. But we really do need to be taking a look at other things that if they dont have to be done this week or this month, can we delay them without, obviously, harming the Public Health. Ill just give you a concrete example. As we enter the fall, in addition to the smoke, were really looking at how do we ensure that we have a comprehensive response to the flu, right, you know, whether the flu vaccine and education efforts and outreach efforts. Those efforts have always been incredibly important, but more important now than ever because we dont want a twindemic of covid19 and flu. So were pulling staff from other areas and actually working across other city departments through our Emergency Response to see if we can provide bring in more essentially more bodies with the right background, of course, but more capacity in order to address this very important issue. So, yeah, i think that as we saw with h. I. V. And i appreciate, obviously, dr. Buchbinder is an International Leader in this work and i think that our h. I. V. Response is building into the institutions memory, which helped to respond to covid19 in the way that we did, we can and we will get through this, but its a long way to go. And i would just ask for the commissions support. Obviously, you know, guidance, and also just ensuring that that people on the frontlines hear that what you care for you support, and most importantly that you understand. Thank you. President bernal and dr. Colfax, i believe that i speak on behalf of the entire commission in expressing our gratitude and support to all of the d. P. H. Staff who have not only taken on dual roles during the pandemic, but keeping the Department Going in the midst of the pandemic. Wed like to make this an ongoing discussion, so please be sure to bring to us anything that we might need to know in how they might be supported in ways they can ensure that they know how grateful we are to them and how much were cheering for them. And thank you, and thank you to everyone at d. P. H. Dr. Colfax, one more question, and you mentioned during your report the disparities that the latino communities are experiencing in the pandemic, certainly, in terms of our transmission in the community. We know that there are a lot of different factors that lead into it, whether its being an essential worker, someone who cannot work at home, People Living in congregate settings, can you tell us about the engagement thats been happening with the community in order to address this and how were moving forward with this . Yes, so as the commission knows since the beginning of the pandemic, we have been focused on the communities most affected by covid19 and we identified early on that the communities at greater risk for covid19 would include the communities at greater risk for other poor health outcomes. And, of course, the stigma, the discrimination and the xenophobia and the environment in which were living in, particularly with regard to including and perhaps particularly with regard to immigration, San Francisco is obviously a sanctuary city and the department provides health care for everybody, regard regas of immigration status. But these are all factors that are contributing we believe to covid19 spread. From the beginning at covid command, we had we had an equity officer and efforts to engage across the city departments and not only at the department of Public Health but with h. R. C. , and the department of Emergency Management and the Human Services agency and others that we were engaging with Key Stakeholders in different neighborhoods with c. V. O. S in order to strengthen our response. As we focused on getting testing initiated and scaled up, we ensured that testing was made available to anyone who was working in the city, including people who are not able to shelter in place for various economic or other reasons. The testing was available because we knew from early on that working during the pandemic is potentially a risk factor for infection. So our broader response, as i mentioned in my directors report, including have included strengthening our Contact Tracing and partner notification in collaboration with really the organizations. Providing those isolation and quarantine hotels. But it is also evident is that we must invest and strengthen our testing efforts in communities where covid19 is most project. Frequent. And we must do better. In fact, we are working with a member of Key Stakeholders and leaders in the Latino Community to develop a communityled communityfocused strategy on how to more meaningfully and sustainably to address the fact the fact that 51 of our pandemic in San Francisco is in the Latino Community. All covid19 response Going Forward must be a latino covid19 response. Clerk . President bernal thank you. I know that well hear more about this in upcoming meetings. Commissioners, any other questions or comments for the director . I do not see any. So, thank you, director colfax. And we can move on to our next topic, covid19 update. Thank you, commissioners. And for this update we have i believe a number of items. We have my update in terms of going through and describing the epidemiology and then i believe that our Health Officer dr. Tomas aragon, and then dr. Susan buchbinder with an update. And to provide you with the latest update since two weeks ago, our last meeting we have exceeded our number of 10,000 cases in San Francisco. Were currently at 10,430 covid19 cases with, unfortunately, 91 deaths due to covid19. In terms of our testing and case numbers, our testing numbers were at 3,401, sevenday average test collected that. Has dropped just slightly over the past week or so. We were almost to 4,000. Just a note here that we had to reschedule and sometimes cancel some testing events due to the incredibly poor air quality. So hopefully those numbers will continue we have capacity to expand beyond the average that youre seeing here provided that weather conditions improve. And were also starting to strengthen our ability to support staff in increment levels in these testing situations. Of course, the smoke is one thing, but as we hope that there will be rain, and we need to make sure that people have an ability to support those testing sites, even in inclement weather. Our sevenday average percent positive is 2. 36 . And then as we have talked about already, we see the distribution of cases and that inequity that is really highlighted here with regard to latino cases. I would also add that this disparity is something that is being seen regionally across the state as well as nationally. Next slide. So this is a slide that really i think that shows the commissioners how we are shifting our testing focus as we invest more in testing. Our popup sites, these are sites that mayor breed announced a month or so ago actually six weeks ago now. The capacity up to 250 tests a day, and we have basically worked with community partners, Neighborhood Partners to establish the popup sites in different neighborhoods across the city. You can see the cumulative positivity is nearly 4 . And then again you can see the positivity among latino clients is very high in some cases higher than the average positivity in all cases of these popup sites. And so as we continue to expand testing in these neighborhoods, particularly the southeastern part of the city, invest more testing resources, we do believe that we will be more responsive, increasingly responsive to the fact that we need to be doing more testing where the virus is actually concentrated. When you compare that to our numbers with regard to our site with the city test s. F. Sites, you can see the numbers of tests that have been done there recently. And you can see that those positivity numbers are low. And, once again, the positivity among the latino clients is high higher than the average overall, but even there not as high as it is despite that theyre not as high as they are at the popup sites. Next slide. This is the county covid19 comparisons of similar size. At this point you can see our cases relatively low, with the exception of king county, the rate below San Francisco. And the death reas rate thankfully is low compared to the other jurisdictions. And our testing numbers with the exception of new york city which in this iteration lags a bit higher than us, with many more tasks before the data is available. Next slide. This is our hospitalization patterns since the beginning of the pandemic. Youre familiar, obviously, that we lowered the curve through june. We had that surge starting in july. Peaking in early august and continuing into the beginning of september. We started to see a decrease down to 51. Those numbers are slowly creeping up again as you can see that were at 76 cases. And we are looking at that very carefully, especially with regard with the heat, the smoke, the Labor Day Holiday and we saw a lot of crowds in a lot of areas. Were watching this. Obviously, we know how to San Francisco knows how to reduce the curve. Weve done it twice now. With social distancing and the masking and the hygiene and avoiding gatherings, and the being outside. If people do gather instead of being inside are really, really key. We know that it works. And what is striking also about this chart is really that the virus is very responsive to our interventions. I think that sometimes in the context of how we are responding to and thinking about covid19, this gives hope because we hav have this can actually be be controlled. Certainly, slowed, if not not stopped, but at this point certainly slowed. Next slide. These are indicators. These are stats which go to high alert, red, for our increasing covid19 hospitalizations. Again, watching that very, very carefully. That is a concern. We will see how it goes over the next few days. Our Hospital Capacity remains good. You can see that theres 28 and 37 numbers. Our case rate remains stubbornly high. Its and down a little bit. And that number got significantly higher a number of weeks ago and were now down to seven, so were watching that. And our testing numbers have already went through and our Contact Tracing and partner notification numbers are creeping up in a positive direction now at 82 each. And then our personal protective equipment, 30day supply is at 100 . This is our this is a slide from dr. Peterson and joshua saab at u. C. Berkeley. And it tracks the reproductive rate of the virus with some of the key interventions. And the calendar dates that have happened since and you can see that shelterinplace is associated with a steep decline and the reproductive rate. We went down then to a reproductive rate that was as low as. 84 . And you can see that another slide there we saw, unfortunately, an increase in reproductive rate commensurate following that memorial day weekend. And then you see, again, that we reduced the reproductive rate commensurate with that hospital slide that the hospital occupancy slide that i just showed you, going down through midaugust. And i will take you to the next slide, please. This is our reproductive rate through september 13th. We hit a reproductive estimate of lower at that point, at the lowest point. 86 , but a few days ago that number is now creeping up and were now at. 88 . With just that at the very corner at the end of that slide, of of above 1 . So that reproductive rate, while going down is slowly rising again, commensurate with that increase in the rate of hospitalizations as well as as well as the estimate that we have here. So were watching that carefully. I will say that in relationship to some of the reopenings that we have announced and as of today that we have allowed, we at this time are comfortable moving forward on those, understanding that with more activity even though we are at lowrisk activities, were likely to see more cases and more hospitalizations. I believe that is the end of my presentation. Im happy to answer any questions here or if the commission would prefer to go through the next few presentations, i obviously defer to your pleasure. President bernal thank you, dr. Colfax. For those following along in the agenda, [broken audio] at the conclusion of the third presentation we will do Public Comment and then commissioner questions additionally. So we can take questions or comments from commissioners now. Commissioners, if you have a question or a comment, please raise your hand. Commissioner giraudo. Commissioner giraudo ed. D my question is in our last presentation on primary care clinics, for the positive cases from the zuckerberg child health center, there were 284 kids that were positive. So did we have any other statistics for the positive rate for children in throughout the city . Is it on the rise . Or do we do we know . I was just a little surprised with the number. Commissioner, thank you for the question. We do have those numbers available. I will get them for you. There has been a shift to a Younger Age Group with covid19. Especially with schools reopening, i wouldnt be surprised to see with the increased monitoring and potentially testing that we would continue to see increase. We can get you those numbers and ill be sure to include those in my next update. Commissioner giraudo ed. D thank you very much. President bernal commissioners, any other questions . Director colfax, i did have a question with regard to the states new blueprint for a safer economy. We know that at the end of last month the state had moved away from the launch list and had moved to various risk levels and we were put in this substantial category, which is the second highest after widespread. We had seen that some of the data would suggest that we we should have remained in the widespread category, but the state had put us in a lower one. Have there been discrepancies in the data, or is that all been resolved . Thank you, commissioner and dr. Aragon im sure can fill in any Additional Information that i leave on the table here. But just i guess that the way that i think about it is that the god news is that were doing a lot of testing in San Francisco. Were doing far more testing than any of our surrounding counties and very possibly than any other county in the state. When the state came up with our colorcoded system, and purple being the highest risk category, and red being the next highest risk, it basically discounted based on testing rates. So if counties were doing high amounts of testing, they adjusted to the amount of testing. They overadjusted for us. So they basically take our k3 and multiply it by. 65 and when we do the analysis, though were doing a lot of testing, our discount rate is more appropriate to be. 85. So 20 over adjustment based on the case. So bottom line is that we have a higher Disease Burden than is reflected in our determination of the state that we are a red zone. We are more like a purple county in terms of our Disease Burden. And so we have to continue to be cautious as we reopen, which is one of the reasons that we are not at this time comfortable moving forward with reopening all of the potential activities that could be reopened in the red zone. Obviously, the state had to come up with a scheme that fits the entire state and, of course, because were San Francisco, we are different and we are looking at our local data and local epidemiology. And, again, in our situation the adjustment of the state overcompensated for our testing rate, the Disease Burden is more of is more in keeping with a purple county. Then, again, ill dr. Adnan pachachi aragon to provide more context. He and others in the department have done extensive analysis on this. President bernal and then just one last quick question. The recent increases that we have seen in hospitalization, we believe that its too early for that to be attributed to gatherings over labor day, that if we see any impacts on that it would be a little further down the road . Its plausible that some of that is, but at this point we expect to see increases in cases first with the hospitalizations. And the hospitalizations would typically occur 10 to two weeks after. Remember, hospitalizations are basically a reflection of where the virus was two weeks ago. So its too early to determine what the effects of labor day are going to be. President bernal thank you, director colfax. Commissioners, any questions or comments for director colfax before we move on to the next part of the presentation. All right, we can move on to dr. Susan buchbinder. Thank you. So im going to talk to you about Covid Vaccine studies that we are sort of more looking at globally about what is happening nationally and internationally, as well what we are planning to do here. Next slide. So what is it that were hoping that a Covid Vaccine could do . Well, were hoping that it would benefit the individual by maybe preventing all infection in addition to just the sevirrity f illness and to create healthier communities. Next slide. So this is an electron micrograph of the covid the virus that causes covid. Its called a coronavirus because it has this crown or circle of light that is made up of these spiked proteins that you can see illustrated on the right. And virtually most of the vaccines that are being developed are really being targeted against this pro fine. And ill show you why in just a moment. Next slide. So this is a virus shown on the lefthand side of the slide and the human receptor shown on the right hand of the slide, a human cell. The receptor is the lock that keeps things out and the spiked protein has a key that opens up that lock. And so if you go to the next slide you can see that the when the virus attaches with the spiked protein inserting itself into the receptor, it opens up the cells to become infected. Next slide. So what were trying to do is to create to teach the body to make antibodies and cells that will help to prevent that from happening. So the green and the purple yshaped molecules that are attaching to the spiked protein are the antibodies that we would be developing against the spiked protein. You can see they prevent the spike protein from docking in the 82receptor by binding to the spike protein and protecting it against infection. So thats the way that vaccines might work. They could either train the immune system to create those antibodies, or we could just infuse antibodies by themselves. And ill get into that in a moment as well. Next slide, please. So this is how we test vaccines and other drugs. Theres a Preclinical Phase that is done in animals that isnt even showing up on this slide. And then by the time you get into human studies, you go through three stages of studies before a product is licensed. Phase one is where youre testing safety and the tolderrabilittolerabilityof tho. And that is usually smaller studies, less than a hundred people. And you get to phase two and youre looking at the best dosing schedule and what the immune systems response is like to the vaccine. And that is usually a few hundred to a few thousand people. And then phase three is where youre actually testing to see whether or not it provides protection against infection or severe disease. So what we need to do is to go through all three phases and what you have all heard about operation warp speed and how much this process has been accelerated. But i wanted to emphasize that the phases are not being skipped. What is happening is that the gaps between the phases are being shortened or eliminated. In some situations were doing joint phase one two studies or joint phase two three studies and some of the bureaucracy that happens between the phases is being removed. So that, for instance, we go to an Institutional Review Board for review of our protocols, usually those sit there for weeks while were waiting for them to be reviewed. Now theyre going to the top of the queue. And so theyre being reviewed very rapidly. So its not theres no skipping on phases. And theres no skipping on the Safety Measures that we build into the trial. And ill get into that also in a moment when we talk about the astrazeneca trial. Next slide, please. So this was the Coronavirus Vaccine tracker as of september 10th. If you look at it today you will see that the numbers have actually been bumped up even more. Youve got phase 25, and phase 1, 14, and phase three, that have been limited Vaccine Limited approval for use. Actually in todays tracker, there are five that have been given limited approval for use. Two of them are in china, one in russia, and two in the United Arab Emirates. All of those vaccines which have limited approval have not gone through phase two testing yet. So we dont have any data yet on whether or not these vaccines will survive protection. And we need phase three in order to make that determination. But you can see that there are nine vaccines in largescale ethicity testing. Next slide. So the way that were testing this is through the Covid Prevention Network or the covt. M. And it was formed by n. I. H. That is pulling together a variety of different sites that many of which were part of the h. I. V. Prevention and Treatment Network to form this new Massive Network of sites across the world. And we have three sites currently in the bay area. We have our site at the San Francisco department of Public Health and h. I. V. And theres a site over at zuckerberg San Francisco general. And ebac, the center has a site in oakland and theres a site at in San Francisco that may come on board soon. The mission of is to have ethicity studies to study covid 19 disease. And the plan is to open up 5 phase three vaccine efficacy trials in 2020. Each roughly 30,000. Theyre very large studies. And infusing the antibodies themselves without using a vaccine but just jumping right to creating antibodies and infusing those directly into people. Those are smaller studies and theyre also currently underway. Next slide, please. So this is a map of the cov. P. N. And we have sites in soutsouth america and in africa. Next slide, please. And these are the five vaccine trials that are planned to be tested in the covpn by the end of the year. And i have highlighted the covpn astrazeneca trial because thats the first one that well be testing in San Francisco. Next slide, please. So what is the astrazeneca vaccine in well, its taking a chimpanzee virus, that causes a common cold in chimpanzees and its altered so it cant cause infection or disease in humans. What its used at is a carrier its a carrier device for bringing in Genetic Information about that spike protein. So that the cells in somebody who is vaccinated will create some snippets of the spike protein and train the immune system, if you see this in the future, and it would be that you see it as part of sars co2 infection, to fight this off and eliminate this. So its a way to train the system to eliminate the virus if its later if youre later exposed to the virus. We have seen that it triggers a strong immune response in individuals, both antibodies and immunicipaimmune cells. This is an older phase, and in phase one and two trials its been safe. You may have heard in the news that were on a pause right now because a participant in a phase two three trial in the u. K. Developed an unexpected illness that could be associated with the vaccine. Its not entirely clear whether it is or not. The evaluation is currently underway. The regulators in the u. K. Have reviewed the data and have made a determination that its safe to reopen the study, so its been reopened in the u. K. Its reopened in brazil and in south africa. But we have were still under review at the f. D. A. And with the monitoring board in the u. S. So were not open currently. It just opened in late august when it got shut down on september 6th. But this vaccine platform, the chimp virus that has been used in 14 different studies against a wide variety of infectious diseases. Next slide, please. So the astrazeneca trial is a phase three study. And it launched on august 28th of 2020. And recruitment was planned for eight weeks. Well be enrolling 30,000 participants, 20,000 will get the vaccine and 10,000 will get a saline placebo and a salt water placebo. We targeted 250 to be enrolled in each of the San Francisco sites and 250 in oakland. Its going to be recruiting people who are at risk for covid19 disease. Its generally otherwise fairly broad eligibility criteria, but excluded are children, pregnant and breastfeeding women, and people with prior or known infection with the sars or covid virus. People will get two doses of the vaccine, one month apart. And theres a final visit at two years. And they get weekly text reminders to report any symptoms so that if they develop covid at any time during the trial that we bring them in immediately, we test them to see if they do actually have covid. And then we do very, very close monitoring to be sure that theyre not getting sick. And we do that for both the vaccine and the placebo because we obviously want to take the best care we can of people who develop covid. Next slide, please. So we do have a number of challenges. Including antivaccine sentiments. And some of this is antivaccine in general, and you can see this person has antiCovid Vaccine sentiment. And has a sign tha, which, unfortunately, it doesnt appear to. So next slide. We do have a substantial concerns on the part of people about getting Covid Vaccine. This is from an n. P. R. Pbs poll done in early to midaugust. If a vaccine for the coronavirus is made available to you, will you choose to be vaccinated or not . And what you can see on the left is that 60 of all adults said yes, but 35 said no. And the rest were undecided. But there were differences based on political affiliation with democrats being more likely to say they would get the vaccine than the republicans. Next slide. Of concern is that there are also these racial and ethnic differences in peoples willingness to get the vaccine. We have heard from director colfax about the disproportionate impact that we have of covid19 disease in the Latinx Community and nationally as well in black african americans. And so we do have real concerns that there may be considerably hesitancy about getting a vaccine from the very populations that may well benefit from a vaccine. Next slide, please. So were doing a lot of Community Engagement and we have a series of listening sessions and town halls with Community Members. We have launched a local website called wecanbeatcovid. Org and we have a spanish version of it. Nationally we have the coronavirus Prevention Network website that people can sign up to be part of the study. And they are launching campaigns now with people in advertising and they have a faithbased initiative. Next slide, please. So we do want to ensure that the recruited population requests the local and National Epidemic and that is true by race and ethnicity as well as by age. Theres a target of at least 25 of the population should be five years of age or older. But well be well be enrolling people with all kinds of exposures to sars cov2. Next slide. This is the covpn website. They have a registry, and already over 9,000 people signed up just for the San Francisco bay area and that distribute include the east bay that had another 11,000 people sign up. This was a couple weeks ago. And people continue to sign up. So we are using that as a way of doing outreach to individuals who may be interested in participating in the study. And because we have the demographics of the individuals that are signing up, we can specifically select for our priority population. Next slide, please. And this is the last slide. This is our website. I encourage you all to go to it. Its wecanbeatcovid. Org. This is artwork done by a local latino artist. So, thank you very much for your attention. Im happy to take any questions. President bernal thank you, dr. Buchbinder. Commissioners, any questions or comments. Commissioner green. Commissioner green m. D. well, first of all, this was an absolutely fantastic presentation. I have to compliment you on making it so easy to understand, really clear. Its really, really wonderful. And i am so grateful to you. And i hope that it be shared maybe for a broader audience, because it really helps people to understand what youre trying to do. I guess that i had three questions. One would be, and more sciencebased weve always had issues with the older population not responding to at least the flu vaccine. And what the thinking is about these particular vaccines . Because i dont know enough about the platforms to know whether the flu vaccine. Or the issue is the virus that people have been exposed to so they dont respond. And the second would be whether this person that got this, it could be an autoimmune response to the component and what the thinking is among the scientist there is and what the tolerance really is for that type of, you know, what is the denominator that is tolerable for that . And then the third would be and this is more in terms of public communication, you know, theres been so many articles written by people about how the Antivaccine Movement is really well organized, national, and kind of ready with their, you know, their prepared effort to kind of discourage people from undergoing vaccination. So im wondering what your sense is of the tools that we have, the incident to which the National Response to encouraging vaccination when we havent really had a National Response to the disease in general. How that will happen. And, if so, where will it come from . We were so good in the bay area to have our counties working together and we do have unique populations that we have to focus on. But id really love to understand what your perspective is and what is going on there. So if you dont want to answer on the medical end, thats fine, but im curious from the commissions perspective of the communication component. Sure, so im happy to take all three questions. In terms of the older population, we dont know whether theres going to be diminished response in the part of older people. We dont have as much data on the immune response yet from the earlier phase trials, because they started in younger people and then moved to older people. So thats why we want to be sure that at least 25 of the population enrolled in the study are over the age of 65 or older, so that we can be sure that the vaccine works in that group. Because theres a diminished immune response in people who are older. Probably irrespective of what the platform is. The second question that you asked was about the transverse myolitis, the illness in the woman that became ill as part of this phase two pretrial in the u. K. It is potentially an immune response. It is seen very rarely in vaccinations, and seeing a variety of different viral infections. We dont know whether theres something about this particular platform that might increase somebodys risk. Thats part of what the investigation is about, is to try to dig in and see if there are any other potential cases that have been reported as that in the press. Although we dont have a final diagnosis yet. Itthat has been reported to us. And then the antivaccine one is a challenging one. And the covpn has created a beautiful ad campaign, doing outreach, particularly to communities of color and to older communities. And also more broadly as part of a movement to try to encourage people to get vaccines and to do this as a way of really affecting the trajectory that we have of the covid pandemic. Theyre also doing outreach to the faithbased initiative, to faith leaders, to try to again, to encourage the trusted members of different groups to support vaccine science. But its going to be an uphill battle because there is really a strong antivaccine message. Some of which is general against all vaccines and some of which is Covid Vaccines specific. President bernal commissioner guillermo. Commissioner guillermo thank you, and thank you very much, dr. Buchbinder. I want to add my my compliments to dr. Green for your presentation and the work that is being done in San Francisco in regards to the vaccine trials. I want to dig just a little bit deeper on the makeup of the participants in the trial. You have indicated there is about 9,000 volunteers already signed up. And i was wondering if there is a way that you could share with us the data on the breakdown by Race Ethnicity and if theres any data on language and socioeconomic status for that data. Because its one thing to have an intent and an outreach effort, but to actually to have the participants in the trial reflect that outreach is really, really important, and not just for the covid19 vaccine, but sort of beyond this. So we can learn something in recruiting for these trials or for other trials in the future. So i wanted to know if you could share that data with us and if there are lessons that can be learned in terms of the outreach and targeting. And then the other question that i had was, with this network, this is a network of n. I. H. Funded trials. Do you have information about trials that are being invested in privately outside of the funding. Will that have an impact on what you learn or any coordination with the research thats going on that San Francisco is part of. And how might that be connected . Because its quite possible that we would have San Franciscos participating in other practice files and that information can be confusing to those who are were trying to recruit for San Francisco, or does it matter . So if you could answer both of those that would be great. Sure. So what we see is not unexpected that the demographics of the people who have signed up are heavily skewed white. And skewed towards english speakers. Although they have the covpn website in spani spanish as welo people can sign up in both english and spanish language. The good thing is that because theres over 9,000 people and were only enrolling 250, we can specifically prioritize those populations who we think that should have first dibs at the trial. And so we have been doing outreach to communities of color in particular and in particular to the Latinx Community. And weve gotten really quite a favorable response from many of the people. Not everybody, but many people are really eager to participate. We have all of our materials available in english and spanish at both our site and the zuckerberg San Francisco general site so that we can enroll spanish speakers as well as english speakers. Unfortunately, we only have it in those two languages. But it does at least broaden our ability to recruit into the trial. And were doing our own outreach in the mission, weve got a number of were doing a presentation with district 10. Were doing as much outreach as we can in our local communities and have our own website so that people can sign on by ourselves. I dont have more data on the socioeconomic status of the people who have signed up, but i do have the Race Ethnicity data. Do we know that Pacific Islanders are also recruited . Yes. Because the data on Pacific Islanders in particular is something that is of concern. Yeah. I understand that we have limited resources, but trying to get to populations that are most affected, then to leave out yeah. And elderly is probably not probably, would definitely be important. I completely agree. And we see the death rates in the older asian population is particularly high in San Francisco. But we need to be sure that we get a really Diverse Group of people who are offered enrollment in the vaccine and then they can make the decision whether or not they want to enroll. Your second question had to do with nonn. I. H. Funded trial. Theres the pfizer trial that is done outside of the covpn network, so thats a large ethicity study thats being done. There is a site in the south bay and in sacramento for that particular trial. What were trying to do is to do outreach to all of the local trials. So, for instance, we already have been working very closely with the site at zuckerberg San Francisco general and at evac and we have weekly calls where we do all of our coordination and a lot of outreach in between. Were doing a lot of outreach to the v. A. Site, and we dont want to cause confusion on the part of participants and it will be critical. Because the v. A. Site will be enrolling in a different trial. Theyre looking at a different trial. So we want to ensure that all of our Community Outreach and messaging is unified, rather than fragmented. President bernal commissioner chow. Commissioner chow yes, thank you so much for this information. I love the pictures and the spikes on the antibodies. But i was also following up on commissioner guillermos questions on a little more broader basis. It looks like the network that were all working with here is a network on your map that excludes a large part of the world in terms of studies. And im surprised, you mentioned england as one of the sites for the astrazeneca and yet theyre apparently not part of this. I think that this whole thing says, how do we really coordinate. And then were hearing that the federal government has already that by presumably by midoctober you should be ready to receive vaccines. So i think this is, again, part of a public trust. How do we then respond to the fact that were doing studies here, and, you know, it looks like this is something that we should indiscernible and were hearing about the western studies, but how do we know which vaccines then are going to be available through this process . And a third thing that we heard, which im not sthaw sure that is correct, is that distribution was not going to be through a private through doctors and their channels, but apparently, supposedly in commercial sites. And that im not even sure of. You know, these are all kind of what is floating around. So how do we gain back trust . This is one part of the presentation and, clearly, a very important part. And weve got at least as you say probably about half a dozen vaccines ready to go. But theyre all in different Little Pockets like this. So which of the six are we going to want to take . Yes, i think that this is a huge question. What ive described is really just a small microcosm, thats just testing the vaccine to see which ones work. Were not the only game in town. So i mentioned the Pfizer Vaccine because thats taking place in the United States, but theres a lot of vaccine trials in south africa and brazil and in the u. K. That are being done currently outside of the covpn. And there are studies happening in the United Arab Emirates and in indonesia, you know, so there are trials going on all around the world, the Different Countries response. And i was talking about what the covpn was responsible for. And in terms of distribution of vaccines, thats really going to be quite challenging. And i think that there are a lot of Unanswered Questions about exactly how that is going to happen. So im really at the earlier stage of all of this, which is just the testing to see whether or not we have a vaccine that is worthy of distribution but once we get one or more then theres also going to be the question, who gets which one. Because we wont have enough vaccine of type a for everyone, but we might have tap type a, bd and do they have different ethicity in different populations and we should prioritize type b for the elderly . Or prioritize type b for younger people . We just dont know at this point. So i think that its going to be a much more complex landscape as we move forward. I hope that answered it. Commissioner chow well, no, youve helped to frame the questions. And yet if these are going on at this time, at what levels then will our own local Health Department be involved . Either working with the state on how the state distributes, similar to i guess what the state did or thinking of doing with testing and has done with, you know, p. T. E. , although somewhat late. And if theyre really saying this is going to occur, whether it be october, november or december, thats not very long from now. This is early september. If we havent been able to answer these questions or possibly i should say who is going to answer these questions . And maybe, you know, i dont want to lay this right on you and in your lap, but perhaps we could move that question also to the departments leadership if you felt that would be more appropriate. Yeah, i think my hope is that it is going to come through the states and then through the city Health Departments. Because i think that we have an Important Role to play in prioritizing who gets vaccine first. We need to be sure that were getting it to the populations at highest risk. Commissioner chow so i guess that i will save the question to dr. Aragon to what levels we are at the moment involved in this dialogue. But i do want to compliment you on really being part of us all in this community being part of the studies that are going on. And the fact that so much has been done so rapidly and i think that is directly related greatly to the work that was done on h. I. V. And the ability to be able to identify these things. And now were really going at warp speed on these things. And much faster than 20 or 30 30 years ago and every step seemed to take about a year before we moved to the next step. Right, thats right. Commissioner chow its wonderful and congratulations and great to have you right there on board. Ill want your vaccine, i think. [laughter]. Well, ill be sure to save some for you. Commissioner chow thank you very much. Okay, thank you. President bernal thank you, commissioner chow. Commissioners, any other questions or comments for dr. Buchbinder . I want to say to dr. Buchbinder i echo my colleagues congratulations for making this so this information so accessible. I am not a medical person and i could understand it clearly. And its beautifully done. So thank you for the way that youre communicating it. Thank you. President bernal thank you. I think that we all agree, thank you, commissioner christian. Okay, if we dont have any other questions, dr. Buchbinder, thank you so much for your excellent and as said, thorough easytounderstand presentation and thank you to your whole team as well. We Love Learning about and supporting your work. Thank you. President bernal already, our third presentation, from dr. Tomas aragon, our county Health Officer. Clerk before we go, commissioners, those who raised your hands before, if you could press the same button to lower your hand so we know when they are raised for folks on the Public Comment line. Thank you very much. President bernal thanks, mark. Okay, god afternoon, commissioners. Today im going to talk to you about the Health Officer orders and the process. So we can go on to the next slide. So the first thing that ill do is to give you a couple slides i had to present recently because someone had a similar question about Health Officer orders. So the federal government collects taxes, can wage wars and can regulate commerce, all of the powers are vested in the states. So the States Police powers are used for Public Health authority. In california, Police Powers are delegated to the counties. We have 58 counties of the 61 health jurisdictions. By law every county must have a physician Health Officer for this purpose. Next slide. So Health Officers must provide Communicable Disease control, including the adequate isolation facilities and the control of the key Communicable Diseases based on provision of appropriate prevention measures for the particular Communicable Disease hazard in the community. Health officers are authorized to take control of contagious infectious or Communicable Diseases and may take measures as may be necessary to prevent and to control the spread of disease within the territory under their jurisdiction. So that phrase there takes measures as may be necessary, is very broad authority. And so that what gives us the flexibility to be able to do the different interventions to interrupt transmission. Next slide. And so im going to go ahead and i received some questions. Im going to take each one of these questions and ill give you a brief summary. The first was the processes for developing Health Officer orders and making decisions for reopening in various business entities if sa in San Francisco. First we start off with what the state blueprint for a safer economy, which is the new framework that the state is using for reopening. Theres another slide that well review some of that for you. So we start off with what the state allows us, and then we look at the department of Public Health priorities. And then we work closely with the City Attorney to help us to craft orders and then directive. And i want to distinguish between the orders and directive. The directives you can think of guidelines or guidance, that is very practical and flexible. But it has the force of law. So think of a guidance with a force of law. Thats a directive. And the order the order usually usually points to the directive. So the order stays constant, mostly constant, and then we adapt the directive because things are changing all the time, the knowledgebased the Scientific Evidence is changing. So we want to go ahead and adapt our directive. The reason that i spent time on this is that most counties do not do directives. And as far as i know, we may be one of the few counties in california to do directives. Because most counties are doing is an order will come out actually, some counties will do just do what state says. When the state comes out and gives guidance and lets counties do it, and the county will say, go ahead and do it. And some may tweak orders and say go ahead and do it. We go through the extra step of droppindeveloping directives. And then we work with guidance to actually provide guidance or tip sheets to complement the directives. So those things that we think that are good ideas, but it doesnt have the force of law behind them. Next slide. So the californias blueprint for a safer economy. So this is the new framework that was developed and you will see there that on the lefthand side, you will see it says adjusted case rate for assignment and testing positivity. So theyre using two metrics. The one is case count per 100,000. If you do a lot of testing, they multiply it down, they weight it down. So you have a suggested rate. So you look at that suggested rate and then the second one they do is testing for positivity. Like, right now ours is about 2. 3 i believe. So its relatively low. Whichever one is higher, thats what your assignment is. So as director colfax pointed out, epidemiologically were in tier one, the purple tier. But because they weighted us down, were placed in the red tier. So epidemiologic Communicable Disease perspective, that does not make sense. We would never say, for example, h. I. V. Is a good example if were out there testing h. I. V. And were finding more disease, guess what, if i see more h. I. V. Infection, i need more intervention. I dont need less intervention. We would not be down weighting those rates just because just because were doing more h. I. V. Testing. So it actually it doesnt make a rational basis. Their explanation for doing this was is that they wanted to discourage counties from undertesting because some counties have a different approach and they want to undertest to find less disease because they want a lower rate. So they balanced their motivation but it doesnt make sense from an epidemiologic perspective. So the way that were approaching this, saying, okay, epidemiologically were purple and we look at what we can open up under purple. And then we look at what is available to us under red and how to use riskbased criteria to open up those things that we believe that can be done safely. Thats a riskbased approach that were doing. So we started with Outdoor Activities and then lowerrisk indoor activities that were opening up just on monday. Were taking a rational approach. So in a sense its the best of both worlds because were taking advantage of what is available to us and doing it safely. Next slide. How does the Health Officer know that the city leadership and impact the stakeholders when decisions are made on Health Orders and reopening decisions. So we consult with subject matter experts. And so that happens that happens quite a bit, actually, just over the past few days we were consulting with genentologist around Skilled Nursing facilities and people who understand the implications of what were going to do. We work with the office of economic and work first development. Theyre fantastic at connects us to the different business entities in the community, especially the Small Businesses, and to work with them so when the directives are coming out we actually distribute them. We ask them is this going to work for you. Give us feedback, are we totally missing it . The other thing that happens is that the Mayors Office and the board of supervisors also gets feedback from constituents. Theyre sending them email. So they pass on all of this information. And then and then others others as needed. So we end up interacting with different business entities, depending what it is. So early on, for example, we interacted a lot with people who do tattoo artists, people who run gyms, restaurants. One thing about San Francisco is that everything is very personal. And so theres just a lot a lot of advocacy so theres a lot of interaction. Next slide. How concerns from the public are incorporated into revisions of the existing Health Officer orders and the decisions regarding reopening. So, again, the same basically almost the same answer which is the office of economic workforce development, the board of supervisors, the Mayors Office, gives us input from their constituents. As i mentioned before we meet with the stakeholders. When im at public im a public hearing, so, for example at the last Health Commission hearing i stayed for all of the Public Comments and i listened to all of that fee feedback. So its important to get that feedback. I get so many emails. I dont have time to respond to them, but i do i do try to read as many as i can. And that gives me some insight of what people people are thinking. And we try to incorporate this into our decisions, because people come up with really, really theyll see aspects of an issue that we dont see. Next slide. And since Economic Recovery Task force and subsidy, how will the Health Officer continue to interact with the business community. So so starting with our blueprint, well start with we start with our blueprint. That gives us access to what we can open. So that gives us an idea of what business entity were going to be working with. And, again, the office of economic workforce development, theyve been a really important partner with us. And then then i have here specific industryspecific engagements. So i pretty much i get contacted by all kinds of people. And sometimes, for example, oewd will say, you know, do you have time to meet with this group of people or that group of people. And i usually, you know, if i can fit it in, i do it. And so, for example, you know, i have met with unions, associations, coalition of Small Businesses. Theres all different ways that people are mobilizing and interacting. So thats been its very useful, especially when theyre organized, just because its efficient for them and its efficient for me when you get on a webinar and theres a whole bunch and they can give you a lot of feed back. They ask really tough questions that are difficult to answer. I dont always have the best answer. But i think that it is a good process to have that. I feel fortunatel fortunate fort reason. Next slide. Since there are so many issues to consider, how are topics prioritized for both Health Orders and reopening decisions. I would say that, first, we really start with the science and Public Health principles. And so we start really with the Health Commission. And the director of health and the department of Public Health strategic priorities. Thats really thats we start with those values, values and principles. We start with those. And then we interact with the Covid Command Center. So the Covid Command Center brings everybody together from the whole city. As dr. Colfax mentioned earlier, we have hundreds of people here in the Covid Command Center and it really it really requires the mobilization of not just our network, but h. S. A. , the homelessness department, its just so complex the amount of work and thought that goes into this is just amazing. I get to interact with a lot of other counties. And most counties do not have the level of involvement that we have. Sometimes it tends to be mostly around Public Health. We really have ours is a total city response. Which is which is pretty amazing. So i learned a tremendous amount. And then, of course, you know, im going to just share with you something that ive i made this up but its actually very intuitive when you think about this. I call it a how to checklist. And the first on Health Equity are true north colors from our Quality Improvement. As were processing different decisions, this is like a checklist to just make you think of things from a different perspective. It makes sure that were complete. So, obviously, were focusing on the Health Benefits and were focusing on equity issues. Ethical issues are really important. And a few years ago i gave you a presentation on Public Health ethics and how we use them. So thats really a critical issue when were making decisions. Were trying to make sure that were doing what is ethical. Efficiency issues are really important because we have limited resources and theres an opportunity cost, and to do one thing and not doing something else. Issues around legal exposures and then, of course, theres also logistical issues and then Political Support and then public Building Public trust. And so a lot of the interaction with the community is building the public trust. This is really important around vaccines and i just wanted to share that with you because its coming in handy over the years. Who is supporting the Health Officers orders, etc. . Is there one Consistent Team or does it vary . So, obviously, the Health Department subject matter experts, administrative support, the City Attorney has been phenomenal. I have i have a Bumper Sticker outside of my office that says i love Public Health lawyers and the love is in the form of a heart. I picked it up at a conference several years ago. Because a lot of Public Health is done through law. But i could have never worked around it as i do now. Most is around tuberculosis or isolating specific cases. But weve had the opportunity to really work intensely with the City Attorney around covid. And i have to just say that theyre phenomenal. Working seven days a week and working night and day and their attention to detail. So its a great synergy working with them. And i auswant to mention that the Covid Command Center, the information and guidance has been amazing. Its a juggernaut of a machine of processing, scientific information, and they have developed like, whenever were working on a work order, theyre working on guidance, they have a whole spreadsheet of whats available across the country. And they keep track of what is being produced across the country. And they systematically have a way of going through this and getting ideas and making sure that were really bringing the best practices as they develop guidance. At some point it would be great for them to give you a presentation. Next slide. And theres complex legalese. How do you make it easier to understand . I think this is a gap area for us. You know, information and guidance does try to make it more understandable, but its not at the level that it should be. Its still it still is it still has quite a bit of jargon. And everything gets translated, and everything is translated i believe into six languages. And then what happens is that the joint Information Center will take those high Priority Areas and then where this gets made more user friendly. And theres quite a bit of activity. And its not enough. And it may have been presented last time and theres a campaign that came out that just came out for different ethnic communities. So theres a lot more work in that area. Its these different areas where the concepts of visitation are really critical. And you have vulner adults. And the attorneys are trying to understand what is available under the constitution, especially around First Amendment rights and what the see wag we do locally. And we have guidances from other areas and we do consultation with subject matter x. And i put here for a noncomplex topic it might take one to two weeks. The first week is sort of doing the work. And then we take about five days just to get it reviewed by everybody. Because we need to understand that its coming to give concrete feedback if we need to adjust things. So theres this process that happens before it gets released. For a complex topic, i said two to four weeks and the reference is the longterm facility. So emergencies two to four days, there was one exception and the march 16th shelterinplace order happened even faster than that. Next slide. Can you provide Additional Information about reopening of schools, including commenting on whether we have available resources to conduct the necessary testing and Contact Tracing . So currently we have 75 waiver letters of intent for Elementary Schools to open. 28 applications have been submitted. Site assessments have started this week and so we expect the approved Elementary Schools to begin opening at the start of next week. And our covid command is developing an operational playbook. That actually puts all of this together that is going to include all of the issues around Contact Tracing and testing. And i just spoke to them today and they feel confident based on the experience learned in the summer with summer camps that they have a process that theyll be able to deploy with schools. I am not aware of any other county in the United States that is doing Site Assessments. Were doing a Site Assessment for every Single School before they open. And we really want i also want to mention to you is that for us this is an equity issue. And we feel were very committed to not only getting kids into school safely. And were getting ready for the spring when the School District hopefully opens up because the those lowerincome communities, communities of color, their schools are going to need a tremendous amount of support and so were gearing up to provide that support. And that includes health and safety plans, site visits, looking at ventilation, everything. So were being very comprehensive. And we have an amazing team. They are just i think you had a presentation that was phenomenal. And thats it. I just want to say that the number of people that are actually actually last friday they surprised me they asked me to give a talk with the Health Officer does and i did that and then its surprising but its just everybody. Its just i was just blown away by the amount of talent, commitment. This past weekend, the City Attorney i. N. G. , some of them were working to 4 00 in the morning to get everything ready for monday. So that we could issue orders and so businesses can open up. And they were just theyve said that on monday they were brain dead because they worked so hard over the weekend, but we got the job done. So, anyways, i just want to give a big thanks to them. Thats it. President bernal thank you, dr. Aragon, and to your whole team and everyone that you mentioned for your excellent presentation and being so specifically responsive to questions from commissioners. I understand that director colfax would like to Say Something before we move to Public Comments. Director colfax. Thank you, commissioner bernal. And Health Commissioners. I wanted to just add my gratitude and to acknowledge dr. Aragons leadership during this time. Hes not only brilliant, but humble. And hes been working right alongside all of the people that he mentioned. And i have to say that he was committed to doing his best and he has been working day and night from february on in addressing this pandemic. And not only the work that hes doing but across the region in regard to other Health Officers and the work that theyre doing. And hes also i dont believe that he mentioned it on this presentation but working in engagement with that. Yerks i see four hands m ill remind folk on the line, if kwr50 ud like to make a Public Comment right now, press 3 ill go in order of the hands i see. So i will unmute you. You should hear from your line. Caller 6, ive unmuted you. Can you hear me . Yes. I can. So ive got two minute on the clock for each of you. When the buzzer buzzings, please know your time is up. Were a San Francisco legacy. Which is 115 years old. We have 12 fulltime employees. Im also a board member of the district of merchants, a merchants association, made up of all the neighborhood merchants. A vibrant District Business is good for the whole city. We provide great, stable jobs, Health Benefits, support fulltime jobs and it becomes a place for the community to congregate. Every decision the Health Department makes has an enormous effect and of course, our employees and all of our community. Again, we are all part of the Public Health. We want to be at table with you making decisions. This weeks new openings brought great opportunity. Were really happy about t. But most of us heard about it through the media, not through the city. This is not very good. Wed like to hear about it earlier. The guidelines, in many cases, werent issued until yesterday morning, the day of opening. We want to do the right thing. We want to be reasonable ask have reasonable procedures for everything. For our benefit and for everybodys benefit. We cant learn about what has to be done at the very last minute. Guidelines should be easy to follow with an outline to go along with them because there are multiple [indiscernible] that can understand. And are very difficult. Time lines, of course, have to be outlined, too. And im talking about the outlines. The distribution of materials will be beeping . Please finish your sentence and your time is up, sir. We look forward to work wealth departmen workingwith. Thank you very much. Caller, ive unmuted you. I can hear you. Great. Youve got two minutes on the clock, sir. Thank you. Ill be less than that want my name is al wil will yams. President of the Bayview Merchants Association and Vice President of the District Council of merchants. I wont go over the points steesk just made, but we certainly say, that bayview has particularly been hard hit by covid and suffered the effects of social disparities over time. Bayview merchants, represent not only the business in the third street corridor in the southeast section, but all business interest in the bayview area. Greatly appreciate the work the department has been doing and working with supervisor walton and others around the covid issues. Im particularly impressed with dr. Buck finders report. The commissioners indicated, it was so, it was presented in a way that i could understand finally, what the whole thing was about. I would really encouraging in terms of working with stakeholders, if you would make that report available to groups like bayview merchants, and other merchant associations so we can get that information out, not only to our members but through them, they can give question that is come to them by their customers. Members of the community, in wanting to r to earn public trust. One way to do that is working through institutions and organizations like Bayview Merchants Association and it is other merchants associations. We also talked about wanting to group the Africanamerican Community more effectively. I think its important to precede the fact that a lot us are a little remember the tragedies of the experiments and the like, so keeping those historical circumstances in mind and using those to help educate would be very appropriate. Thank you very much. Thank you for your comments, sir and the presentation is on line on sfhc. Org. So the next caller. We have got a few more callers, commissioner. Let us know if you can speak. Yes. Okay. Great. Youve got two minutes on the clock. Caller thank you. I am the president of the San Francisco council of district merchants associations. We ad for 43,500 70 tiny businesses that are in San Francisco. Tiny businesses that we consider to be 10 businesses more or less and sad to say, it is declining dramatically. Were reaching out to you, today, to thank you for your tireless efforts in these unprecedented times. We are today, to find the citys recovery and youll be remembered for these efforts so i really want to thank you again. A few small points but they were already highlighted and made by the previous callers. Is that, you know, all of us small bees, 45,005 70 of us, im going to guess that about 75,000 of us are store Front Properties with relationships and confidence with our customers. We are a tool and an asset that we can use. Please bring us into the discussion. I also want to reemphasize that a healthy economy is also symbiotic with a medically healthy environment. Think about t. People that are employed have a higher selfesteem, have a better outlook on life. Probably have better medical benefits and a greater income of what they would get if they were on unemploy m and typically, will be able to seek medical help much earlier before things get bad or be more proactive and preventative in the medication because the that disposable inc. Economic health and medical health are symbiotic relationships. They cannot be siloed into two separate parts. They need to work together. I believe that if you reach out to the smaller groups, through the council of district menshants or directly through the merchantses yourself. You will find a receptive organization, that will be not just receptive, but an asset. Thank you. All right commissioners, a few more calls. Ive unmuted you want please let us know if you can hear me. Yes. I can her. Youve got two minutes on the clock. Im coowner of the fitness, board member of the castro association and San Francisco Fitness Studio coalition. I want to applaud the city for the work to get some aspects, to get it reopen at 10 . Too many small neighborhood Fitness Studios t can mean the difference between the life and death of the business. To have substantive conversations with their landlords and employees and provide an additional ongz for San Franciscos residents for poor air quality and those who have Fitness Options simply dont work. But dph. Dr. Colesons and dr. Air considered an essential service to help our citizen fight covid. In many cases, its no different than physical therapy, as dr. Air gone has noted. As this pandemic evolves, including the potential [indiscernible] iindisthepotent, please dont forget that. Thank you very much for your comments. We have got one more caller, commissioners. All right, caller, you are unmuted. Hi. My name is tracy sylvester, owner of espiladi, in San Francisco, on valencia street for over 28 years. Im on the board of mission menshants association, a delegate with the San Francisco council of district menshants and a member of the San Francisco independent Fitness Studio coalition. Ive been advocating for Small Business for over 10 years. I want to first thank you all for your effort and i look forward to becoming a partner in communications. So im grateful to reopen the business. It has been devastate for example our clients who are in severe physical decline, and are desperate for our services. As david had just said, whether in person, online, we know that its an important part, movement is an important part of wellbeing. And wed love to see more communication from the department of Public Health, promoting exercise and wellness, especially during the pandemic. Five reasons for staying active during the pandemic include relieving stress and anxiety, supporting immune system upon managing weight, improving bone and muscle strength, increased flexibility. You have an remembery of people out here in the community, that are interested in the wellness and wellbeing of our citizens. Secondly, i wanted to talk about Contact Tracing. Everybody coming into our businesses. We have the ability to contact and know exactly what the flow is in our building. We dont really have any guidelines qhaf it would take for us, if we found that one of our employees, members or staff were around somebody that had covid or if there was somebody that tested positive within our environment. How far do we go to public trace, who do we communicate this to, and how do we help become part of your army, in order to help mitigate the spread of the pandemic. Thank you. Commissioners, we have one more. Caller. You are unmuted. Im a member of the San Francisco independent Fitness Studio coalition. Im a previous owner of a brick and noter that had to closed, due to the extended shelter in place industry, some of my points of course mentioned already so ill try and be brief. Ill reiterate what was said about the plan to commune occasion for open guidelines. Left a lot of owners scrambling, so the exiewnication about guidelines, and the time frame would be instrumental in allowing them to properly prepare and open effectively. Secondly, now that we are allowing indoor fitness, we greatly need the Departments Health support, dr. Colfax, i know you mentioned a few weeks ago at a press conference that you wouldnt mind exercising indoors. Currently, were at 10 capacity, allowed with the next stage being 25 . We need to know if San Francisco will follow ute suet with that. Of course, thats dependent on cases. One of the greatest travels over the past 6 months while we have been closed was not knowing what was planned. I know dr. Air gone mentioned, communicating with different business sectors, we did have a lot of frustration of our coalition in communication. We did not necessarily know their occurrence. So again, we applaud your efforts. Thank you, but please help us communicate as much as you can. Thank you for your time. Thank you very much. I think dr. Colfax, director colfax mentioned thad dr. Air gone is in communication if these discussions are already going on, on a state level, it seems to me that it would be just as important that the counties have a greater awareness of what is going on. Apparently, there is no real plan yet, but i do think its important that the county department have some sort of role in understanding on how vaccines are going to be distributed to the population. They havent engaged a local Health Office yet but the Bay Area Health official on the monday call are going to start bidding up on this very topic this thursday. So at least in the bay area, were were going to Start Talking about t. The other thing i want to point out is were taking advantage of influenza season, as the opportunity not to just vaccinate people with influ ens a but to really exercise the Distribution Operations to deliver a vaccine. So for example, were going to be offering influenza vaccine at the covid testing sites so were beginning to operationally, what is it going to take to vaccinate a lot people, people qhosk driving, come in and have driewf through vaccine. So we arent thinking about it. Well be able to give you an update action soon as we have more to present. A bay area [indiscernible] i know you made the comment about trying to make the Health Orders a little more readable for that general public. I would just highly recommend that in Going Forward, you really try to have maybe a summary at the end at the fifth grade reading level, which is what is considered what the general public can read. So i would highly encouraging you to have that happen. But thank you, thank you, for all of your hard work and im sure you havent had a day off and we so appreciate your your work. Thank you. Commissioner green. First off, i would like to echo gratitude, for every in the command center, and everyone and what the dph have been doob, and the hours dr. Air gone sure makes internship seem like a parttime job. I also want to recognize how many members the department have had to pivot, not to develop new skill set bus also operationallize them. I know with your job in particular, involved, you know, going from a lot of lean management and longitudinal thinking to immediate action hero type activities and i think youve done a spectacular job of making that pivot, as have supported everyone else in the department. Its such a pleas tower hear the el qens, taw thoughtfulness and intellectual capital and really caring thats gone into the work youve done. I know youve touch bod it and i think this echos with both commissioner duradohad said. The communication part is so important. I hate to see these incredible efforts be misunderstood or not actualized because were not doing a good job of communicating to the public. And theres a lot behind what youre doing. Itso important for people to understand. I think when you look at the vaccine as well, were being to especially have San Francisco more pro vaccine or perhaps other municipalities around the country, if were not only going to have them avail thepgzs of vaccines, but also, especially some of our communities of color ensure that people understand and understand the logic. I think were so its so important to focus on those resources. Personally, i found some of the orders for hospitals confusing to me personally, like [indiscernible] during care. So i was wondering if you could think out loud or elaborate a little bit more on what you foresee could you talk any insight can you give, any reassurance about clarity would be really helpful. I used to run the cdc Public Health preparedness training center. Resource center. One of the things we learned about disaster ises is in the after action reports, the three top areas where you need improvement is communication, communication, communication its just so big and its so important it is an area where we can be really creative. Ill give you a concrete example. Yesterday, i was asked to speak at a training, these are monolingual spanishspeaking women who are learning how to engage the Community Around covid. Really what we have to do, i think the communication, we really have to do it in a way that engages people. In a way that they really understand i enjoyed working with them. I said please, invite me back to speak again but can i only do so much. We have to figure out how to tap into the injen yewity, and community, really around the communication strategies. We communicate through our channel that is we are accustomed to, in the language that we are accustomed to. And i can actual, i know its not reaching the community that is need it the most. It made me think right now, we have to do a lot more of that so actually, dr. Colfax may have mentioned were going to be working with the latino pastors, to train them to do the Contact Tracing. So they are going to be actually doing all of that and i think we have to do more of that mobile life so it gets translated as a level that really mobilizes the community, much better than we could ever do it. What leams of the city,. Yeah, so we do have a joint Information Center. A joint information Center Brings in the communication people from all the different departments so they have, a few doors down, they have this big room. This whole, theres an army of them working on this. But even with the army, its not enough. Its not enough. And i think were getting better. Were getting better, and i think this is where i think we may have to bring in some outside resources, engage more with communities, firms that are actually working in the Community Around us to really do a better job. But we do have a team of people. Again, at some point, maybe have some of them come and show you how their process of developing materials. I think its wonderful to hear back how its going. What kind of resources youre bringingbringing and innovatiod the whole fear of public communication. We can do that. Qhish nears, any other public or comments for dr. Air gone . I just want to thank you again. This presentation helped us understand the enormity of your work. Know San Francisco has stood across and that is due in large part, to your extraordinary leadership and i dont think that we as a commission can over state our gratitude to you for your leadership, for your thoughtfulness in how you approach your work chuck neb niche near green, ill add that action once its available. I know i speak for the entire commission. Thank you. Well be moving on to general Public Comment. Yes. If you would like to make a general Public Comment, which means youre commenting on something that is not on the agenda, a topic not listed on any other item on the agenda, please raise your hand now. I see one hand. My name is christine galloso. Im a Small Business owner in the adult recreational sports space in San Francisco. This summer, you guys allowed use pods to play with approximately like, lessening children at a stayed in those pods and thrirp a throwed scrimmage and play soccer and have exercise and recreation with each other. But the conditions have been [indiscernible] for adults recreational sports on a state level or a local level and now, childrens pods of course reduced to fitness where they have to stay 6 feet a art part from each other. Id like to know the reasoning to the switch, august to september, that kids can no longer participate in scrimmage activities and pods and why adult recreational spoarpts have not been considered in the return to participation i think its an area that the Health Department i thank you for your time. Thank you for your comment. Commissioner, that is the only call that we have got. Yes. Well move on. To the community and Public Health committee update. We had two items on our agenda, the first was the hepatitis c update which was an excellent report. And there was a pause in moving forward because of covid. The Street Medicine Team are back. They have been in operation and Going Forward. The second one was a very intense presentation on the primary Health Clinics within the city qat duty, and complex, as well as specific challenges with covid and what their plans are Going Forward. It was an interesting meeting. Secretary do we have any Public Comment . I dont see anyone. If youd like to make a Public Comment on the side, please press 3. This is commissioner dorados fist meeting at chair. Any. Any questions or comments for commissioner durado . Commissioner chaothey spoke about when thri might get back to their scorecard, that has more than just samples of the primary care were doing. Realizing, covid has disrupted, obviously, a lot of quality measures at this point. But i think it would be appropriate to have the scorecard reviewed again. At an appropriate time as we give them some distance to get back in order. Its going to take time, many of the staff have been deployed for covid. Many are on leave so they are moving as quickly as possible and will be reporting back to yous, as things did forward. It is something that even the hospital and managed care, they are actually retooling again, and starting to activate the processes for assuring quality. So im not look for example something immediately, but i dont think it should be dropped. We had a process in play before covid arrived, and they were really making progress and id hate to see that sort of lost. In our presentations, it will not be lost and data is continuing to be collected. As much as possible. And the presentation was excellent with the database, especially as they are operating with covid. Thank you. Any other questions or comments on this item . If not, thank you again, commissioner duradofor that report and for taking on the chair of the community Public Health committee. Well move on. To the next item. Epic update with erik raffin. Not yet. Can you maximize your screen. There we go. Im the chief Information Officer and im pleased to provide a quarterly update on our epic comprehensive Electronic Health record program. I have some cocontributors to thank for some information i shared today. Dr. [indiscernible] mr. Sarapia. Mr. Upchurch. Really, all contributors for what well go through and ill try and expedite because i i know the meeting is rung a little long. I adopt to say that most of the material you see today, is in response to your questions from last time im looking forward to sharing answers and keeping us moving forward with how were doing having a voice with our patient and important aspect of providing a big software program. I think its so much more than epic. Two short vignettes here. The first is from one of our patients. But id like to draw your attention to the second one. The software, with the ability to access your Health Record fist youre on a computer or on a mobile device. Youll see them in the second vignette. An elderly patient with dementia, has proxy access to his mothers Electronic Health records. This is an extremely important point i want to make right up front about the power of being able to gain sages to Electronic Health records as a parent, i benefited from having assets to my childrens records as they got older. I know if indicates such as the one you see here on your screen. Its really important to understand that patients who are unable to gain access to work within this tool, someone that they trust, we have rebooted our governance program, were beginning optimization work in some of our domains and we are in the midst of working through our second implementation leg. My take home message is 4 parts. The reflections about the security of the epic system, and i hope we leave today, with the understanding it is a secure environment. Were going to talk about my chart, and adoption is on the rise. Im here to talk about Revenue Cycle and how those operations have stabilized and well conclude with an update on the alignment with the spend, through the first three years of our project, and how that aligns with the rest of our epic experience through 20 twesk. So very quickly on secure and Health Information another not just about ethic, its really about everything we do here at dph as well. While there are plenty of very technical things that go on in the middle two sections of this slide. I really like to focus on the book ends. So on the left people, are the primary means of deterring private security threats. Its so easy for social engineering and other types of human behavior, to result in compromises and breaches to information that is really important to not just a policy, but to have at least annual reminders, so that were also vigilant. The city has adopted a new studio Awareness Training program which is now mandatory for everyone who works in city and county of San Francisco. On the far right, just as a reminder, all of the good work we do to protect our environment, its never perfect. And i do want to mention that we are externally audited every year through the Controllers Office and there by, auditor. We are working through findings from the current lead leaders odd r audit in a significant plan of action. And our goal to do use techniques of understanding causality of the findings and making sure we can prevent their reoccurrence. On the epic side on the ethic side of securing our information another really about authentic occasion and authorize ah, thenication. How are we communicating back and forth and how are those communications threatening, and that, in all of the laws, that govern break the glass, both at the state and the federal level, allow this emergency use case to occur. Working can your medication and managing your appointment. I believe there was a question are we able to manage telehealth appointments yet. Through my chart, the answer is not just yet. When we do that, well be obviously, greatly improving expanding and unifying our telehealth experience and we hope to be able to then offer more enhanced scheduling for those appointments. Most appointment management today, through the my chart tool is for primary care. For our activation rate for my chart, basically, how many patient dos we have, we consider active. A little over 10,000. 10 percent to 11 percent zone. Not surprising to see most of our my chart users by h cohort are between 18 and 65 years of age. I was actually really pleased to see, that 60 of my chart users are over the age of 65. Some of those include some of the residents. We move to the right, and look at preferred language, just a reminder that perved language is something expressed english is their preferred language, although 9 spanish, and 7 cantonese also made it on our list, as well as all other languages. And if you want to take a slice by race and ethnicity. We request see across the board, can you look at the horizontal access. Those are the rates, categories that are in if you look at the map, 10,288. That allows us to record patients who express that they are multi racial. When you look at the bar. You will see two colors, orange, being an indicator, ethnicity of nonhispanic or unknown and blue being hispanic ethnicity. So this is the way to look at our initial firstyear view of epic my chart user byes rates and ethnicity. The things that we have done so far, that are most important on the left, are that my chart wasnt something that was just deployed. My chart, just like the rest involved a lot of input and in this case, input from pates. From patient advisers, who are involved with many decisions about the design and look and feel and functionality of my chart. My chart is currently available in english and spanish only. More languages should be written in and coded in to the softwares that support the my chart capability. But i think thats the flip side of that concern is this is a proxy consent, much like the [indiscernible] that shares the beginning is important. Because if somebody is unable. Because they are not fluent in english or spanish and they have someone they trust, they can grant that person proxy access to their record and that can really help the engagent with the patient. And to help navigate the health care experience. On the right side, what are we planning to do, were really trying to understand where we have disparities and how we go about closing the gaps. I was reminded this afternoon. Just before this meeting started, my chart is a piece of software. And is assumes you have access to a computer or smartphone, and the internet and that you can actually afford to do those things and thats doesnt compete with food, shelter or education or going else. Ensure more people with take more command of their Healthcare Experience with us, with the understanding that not everyone has access to a computer, and the internet and a smartphone. Arcr, after a lot of challenges at go live and of course, challenges with covid19 as with our dramatic decrease in operations, which means we werent collecting as much revenue. The ways i know that were stabilize side that we are now starting to collect more per month for Services Rendered than we did prior to having epic. I think its a little later than we all wanted it to be. But we are starting to see those collections trend in a favorable direction. And epic actually recognized the folks with access and Revenue Cycle in dph with recognition for basically, a solid install called the automaticimation pulse recognition. I had a hard time understanding what that meantime, too. But essentially, what it means is that we have completed a very thorough employment of capability that allows us to do access and Revenue Cycle and we are allowing claims to go out the door. We also know there is still a lot of opportunities to collect more revenue. And some of the reasons we know that are because of the analytical capability that is epic provides us. Where it sundays us lots of signals and gives us a lot of intelligence about where we should be looking to understand where we may not be capitalizing on this opportunity. So thats our way forward is to use the analytics to make sure that we can improve whether it be the human processes or technological workflows to maximize all the Collection Opportunities before us. In 2019, followed by a stabilization period that took us to the beginning of 2020. What we havent talked about is when you implement new software, you usually have to free the version of the software that youre on so you dont change it as youre training thousands of users and making lots of configurations. So we were no different than any other organization and in the early part of 2020, we flished three upgrade its one time, which was a fantastic accomplishment. It resulted in a very short amount of down time for all of our epic users. If we move forward with wave 2, which we reset our expectations. By nature of how you see all of the subparts of what make up wave 2. Everything from integrative care, and coordination of care, all the way down at the bottom where you can see the last row where we have integrated video visits and interpreter services. Thats what we were tbawsmght integrating services into the my chart experience. Each one of these can be a justed and moved around and theyve been as a result of our heroic response to covid19. So we have adjusted so that we can accommodate when our line of business appearance are ready. There are a lot of people chomping at the bit to move into the epic environment. So we are flexing and adjusting to make that possible. So its committing to see that were able to actually still maintain our Covid Response and take on components of our epic program thra if you ask me back in march, with the time of shelter in place. I think i would have said, i dont think were going to do anything with wave 2. But this is an Amazing Organization and we are continuing with our work. Finally, to talk a little bit about our h. R. Budget, some knowns and unknowns when i spoke in early july, we have wrapped up. We have learned a lot about what we actually spent, against what was predicted, against what was budgeted and that has helped us predict, spend for the remaining years of our epic experience. We also know after reconciling many, many contracts and purchase agreements that consulting cost consist bring up a big bill. We are going to take a more surgical approach, as we need a boost or as we need expertise that we simply dont have, that we need to get us over the bump of design or implementation and we become and save the owners of the work. I think its important to comment that we have really very few consulting resources right now, as weesk operating over the course of this calendar year. We will start bringing in ray few here and there, as we start moving through more wave 2. Top right, something we dont really know, are all of the subordinate contracts for epic. Epic is huge. We all know that, but we have about 5 dozen other contracts that help support all the different aspects that we epic do themselves. Enhancing our telehealth capability. In order to do that, we have to partner and have an agreement with an organization that can do sort of the audio visual part of the work. And that has the right linkages into the Epic Software so woo y wee can combine epic with the partner solution so we can have an experience in my chart, with the video visit. We have a number of these contracts that are still yet to be awarded and several of them havent even been through the rfp process. We have done our best to provide good estimates the future year costs through 20 twesk of both contract you and our staffing for epic were under separated. So im going to move to the numbers to see how that actually pans out. Fist line is proposed budget, which is what your comitionz saw from some years back request that was assembled. What you can see beneath that is what we believe to be our actual ehr spend for that period of time. When i met with you last, we had predicted that we might have to dip into our project contingency. As it turns out, request we reconciled all of our contracts at the closeout of this fiscal year, which was obviously a really big one, it was our golive year, we ended with a positive variance. That was important. As we move to the next column to the right, fy21twesk which is our estimated budget, youll see the proposed budget was about 140 million. Were actually estimating that our ehr spend is going to be closer to 211 apply our project contingency, which we have not had to touch. And apply our net balance from our first three years of work on epic. Youll see that we are just slightly positive. And so im glad to report thats our current status. I think my take away from that is being responsible for ensuring that we stick to both our targets and our budget is that we will be paying close attention to have we have enhanced our estimates and understand variances on a more frequent basis, now that we are in regular and normal operation with this solution, but also, were still i. Implementing. Ask i leave you with this quote from president John Quincy Adams but it explains a lot of what is going on in our organization. So much perseverance and patients and im pleased to take your questions. Thank you, mr. Raffin. Do we have any Public Comment . Those of you on the Public Comment line, please press 3 if youd like to raise your hand and make a comment. Ill give you a few seconds. I do not see any. So we can move on. With commissioners comment. Commissioner green. Fist, thank you for the presentation. I think we all feel from implementation othe epic project has really succeeded beyond our expectations. So congratulations to you and the team and also to the seamless transition and leadership which i think came at a very difficult time. And i applaud you for having done that so well. I had one question about my chart. Are you gathering any data . You know, there are four areas you can use my chart for prescriptions, appointments, test results and for contacting your doctor. I was wondering if you were keeping any roarsd as to proportion of which those 4 possibilities are being used and also, knowing that our system means that doctors may not, we have many people that arent in clinic every day and so as people start to want to contact their doctor, what kind of guard rails are we putting there. So ask, people will send something vee at website, thinking it will be read in 5 minutes and i just wonder, especially in our system. What kind of guard rails we might be putting in],the communicate withing your doctor component on this. I dont have the data, im confident, i know that we have a guard rail on what to expect when you send the message to your provider, as far as a response and a reminder even before you sign up for my chart of what tox peck as well. So we can get you exact information. To your first question on the data im sure that we have that available. Again, i dont have it at my fingertips. Ill be happy to get it and break that out in as much detail as we can. Somebody responds to you right away, its going to be very confusing to patients to figure out what the best modality is of reaching out if they get so fatigue and next thing, youll find something. I mean, that happens to me. Im in labor. Oh, god. You sent me an email. You know, that kind, how were going to go forward with that. Yeah, its no trouble to get that information. I can answer that so hi, commissioners. Its clerc and ive been really pleased pleaseh how its rolled out in primary care. We dont have that many my chart user bus my patients of course very pleased with t. And i think holly and robert have done a great job setting it up, we have the call center the and nurse advice line so we can knock off all the issue that is can get taken care of by a teambased care and patients are informed that they are sometimes a bit more of a way for us to get back to them. But it really takes care of soy many issues. We have a protocol for cuing up prescription refill when is that comes in by call. Getting paicialghts on my chart, and i think that can help them across a Digital Divide and id love to be a part that have solution to them. Too. L thank you for the presentation. Im really excited about number to begin with as a data geek. And with what dr. Horton just mentioned, i was wondering if we as a commission would be looking forward to like, future reports that actually indicate how the adoption improve User Experience and lead to Better Outcomes and like, improve streement strategies were just coming out of the first year using the tool. So thats always luck to use data from your first year. But i do think were going to be able to provide extensive information that we can track in a number of dash boards about how well were doing. Its really the first time that we have that face where we have the capability to see what were doing scrks share that information with others, such as this commission, in a way that is more unified and complete than i think we have probably been ever able to do. So with a years worth of data, we are starting to understand, thats how, for instance, othe Revenue Cycle side, were feeling much more confident about where we are as weesk able to seat trends. Week by week and month by month and its really no different to look at how were operating medically as well. Where we can see a lot of our measures and Key Performance indicators. Its something we can start bringing forward and encouraging folks to ask us more questions so that we can bring you those answers and show you exactly what it looks like. Thank you, i look forward to it, dana. Thank you for the updated implementation sequence. I would imagine that knowing all the things that have happened, one, which youve englished already, we can follow. Two as the road maps that you have. So i was thinking that we might be able to get is seeing the new budget, essentially that you have for the coming 6 years in terms of what youre look at to spend, to build out the rest of wave 2. In the past, when these contracts came before the commission and they were enormously complex with multiple contracts as i know mr. Wagner was aware of, we were able to put them into context because they were broken out into buckets and we could tie them to buckets so that we could feel that tarpnt just that you went and today was september 15. This is the one wed like to present to you. But wed like to sort of see this at the budget commit easy part of the whole. What is the whole that were doing . So maybe were not prepared to do that right now, although you do have some estimates perhaps a presentation as to what this new build out over the next six years are going to look like. And how youre going to be bringing subcontract ors in. So when the contract ors actually hit the committee, they can be slotted in and be seen as as part the schemes that have been worked out. Those linkages will not be terribly difficult and i think it will help ground everyone in how to spend capability that is were adding to the epic program. The model used during phase 1, really, i dont want what the chair budget things but i thought that actually worked out quite well as we saw the different component parts. Not at this moment, but thank you for bringing that up. Any other detail . s all right want thank you very much for your excellent presentation, its been exciting to see how this has come along over the years and how useful this tool has been as we also navigate a pandemic at the same time. I think we will not be be in as good as we are in now, without epic and the state that is it is in. Thank you. This is grant colfax. Can i just add my gratitude to erik, mr. R affin and his team. Its just been a year since we have implemented, a year and a month. Seeps loppinger than that and the culture of epic has really taken root root in the department and also with our covid19 response, we are now planning link other epic for us to be able to better monitor the pandemic. So, so much progress in just a year and a month and just appreciative of all the work thats happened. So thank you. All right, thank you, mr. Raffin. Well move on. To our next item which is other business. Commissioners. Any other business . Okay. Well move on. To joint Conference Committee reports. Commissioner guillermo, had some issues. Yeah want i can hear you and i pulses. Somehow i got frozen out of the meet expghts webex so im calling in. We received a report from Michael Phillips qhorks is still relatively new to honed a. As unfortunate we have not had a chance to meet him in person, he jumped right into the position and gave us a thorough report on the status of things like niguna honda and a finance report which we have not been able to get updated last time. Which was good news because it appears that were doing quite well at la gunna honed a. One of the things that Committee Members are always interested in is the data on residents who leave the hospital without being discharged, i guess awol residents and patients and although the data has improved, in the situation has improved with regard to those residents, and the ability to follow up on them, the Committee Member commissioners who are interested in just getting a better understanding of those awols and how social Services Follow up. If conducted with them. So well be getting more information on that in a future report. We again, reviewed the Regulatory Affairs report, those are still pretty much on hold because of covid and so there is not a lot of information that we were able to get, with regards to status of the number of facilities reported incidents. We did have a good presentation on the culture of saist. A survey that was implemented last year at la gunna honda in october, was supposed to be retaken in may of this year, but again, because of covid19, it was postponed until august the sponse rate was much smaller to last year, it did show throofs a slight improvement from staff in terms of the sense of safety, s, but there are still a few areas that need more outreach, more followup and more data that we will be hearing about in particular, probably in november because the survey will be taken again in october of this year. And theyll be doing a conservative outreach to make surety Response Rate is as close to, the Response Rate as we had last year. Then we wante we went into closd session where the committee reviewed the Quality Improvement report Patient Safety Group Minutes and we approved the staff credentialing report and that is the extent of my report. Thank you, commissioner guillermo. Do we have any other other questions about the laguna honda jcc meet . G seeing none, we can move on. To our next item which is adjournment. Do we have a motion to adjourn . So moved. Is there a second . Second. I will do the roll call commissioners. Commissioner guiellermo yes. Commissioner dorado yes. Commissioner christian yes. Commissioner green yes. Commissioner bernall yes. Commissioner. Commissioner chung yes. Commissioner chao no response . I think youre muted. I forgot to unmute. Yes. All right, thank you much. Thank you much to the team at dph for your excellent work. Were so grail for you and proud of the work that youre doing. Hang in there and well see you all in two weeks. Thank you, commissioners. Thank you. adjouradjournment 6 50 p. M. Pd. You. What do you think about working at an airport and i love it is busy all the time. We want it to be an those away was this is a venture if i didnt love it ill be an accountant. We want the experience that is a nonairport experience the negative stigma were trying to erase that. Everything is in a bad food to excite them about the food and they have time to learn about us. People are imitated by traveling and the last thing to do is come to a place fill of chaos. Telling me how the extent of napa a farms came about. It was a vision of the airport director he had a suspicion of a really cool gourmet speciality market locally friendly products this market local flavors this is the best. Can we get a little tour. Absolutely laughter so first on our tour. We have the clock we like to call it. This is coordinating it is made in San Francisco. What about the customer presence. We like to get the permanent farther i love the cappuccino and you have to go to multiple places for the cupcakes the cup a cakes from karis people want to live here theyre longing phone call for one thing in one spot in you know anything about San Francisco the cheese the most popular cheesy think a lot of the people from the west coast say so this the real San Francisco sour dough and theyre curious. You find people respond to the idea of organic and absolutely. This is autumn. Thank you, thank you and theres a lot of personal touch. I see San Francisco. Its very hands on. Whats the most popular items. This is quite surprising our fresh jotting this is the chronicle special a bowl of warm oats and coconut thats mites farther. And speaking of drinks tell me again the cocktail scenes is that one, the things your known for. The cocktails are fantastic. Really. Fresh ingredients we dont have a mixture it to order this is our marcus bloody mayor. Farmers market bloody mary the bloody marys in the airport are great shikz it up. And then were going to garnish it with olives. And some lime and a fresh stalk of selly. Right on. We like the San Francisco playgrounds hitsvery dates back to 1927 when the area where the present playground and center is today was purchased by the city for 27,000. In the 1950s, the sen consider was expanded by then mayor robinson and the old gym was built. Thanks to the passage of the 2008 clean and safe Neighborhood Parks bond, the Sunset Playground has undergone extensive renovation to its four acres of fields, courts, play grounds, community rooms, and historic gymnasium. Here we are. 60 years and 14 million later, and we have got this beautiful, brandnew rec center completely accessible to the entire neighborhood. The new rec center houses multipurpose rooms for all kinds of activities including basketball, line dancing, playing pingpong and arts can crafts. You can use it for whatever you want to do, you can do it here. On friday, november 16, the dedication and Ribbon Cutting took place at the Sunset Playground and recreation center, celebrating its renovation. It was raining, but the rain clearly did not dampen the spirits of the dignitaries, Community Members and children in attendance. [cheering and applauding] [ ] i just dont know that you can find a neighborhood in the city where you can hear music stands and take a ride on the low rider down the street. It is an experience that you cant have anywhere else in San Francisco. [ ] [ ] district nine is a in the southeast portion of the city. We have four neighborhoods that i represent. St. Marys park has a completely unique architecture. Very distinct feel, and it is a very close to holly park which is another beautiful park in San Francisco. The Bernal Heights district is unique in that we have the hell which has one of the best views in all of San Francisco. There is a swinging hanging from a tree at the top. It is as if you are swinging over the entire city. There are two unique aspects. It is considered the fourth chinatown in San Francisco. Sixty of the residents are of chinese ancestry. The second unique, and fun aspect about this area is it is the garden district. There is a lot of urban agriculture and it was where the city grew the majority of the flowers. Not only for San Francisco but for the region. And of course, it is the location in mclaren park which is the citys second biggest park after golden gate. Many people dont know the neighborhood in the first place if they havent been there. We call it the best neighborhood nobody has ever heard our. Every neighborhood in district nine has a very special aspect. Where we are right now is the Mission District. The Mission District is a very special part of our city. You smell the tacos at the [speaking spanish] and they have the best latin pastries. They have these shortbread cookies with caramel in the middle. And then you walk further down and you have sunrise cafe. It is a place that you come for the incredible food, but also to learn about what is happening in the neighborhood and how you can help and support your community. Twentyfourth street is the birthplace of the movement. We have over 620 murals. It is the largest outdoor Public Gallery in the country and possibly the world. You can find so much Political Engagement park next to so much incredible art. Its another reason why we think this is a cultural district that we must preserve. [ ] it was formed in 2014. We had been an organization that had been around for over 20 years. We worked a lot in the neighborhood around life issues. Most recently, in 2012, there were issues around gentrification in the neighborhood. So the idea of forming the cultural district was to help preserve the history and the culture that is in this neighborhood for the future of families and generations. In the past decade, 8,000 latino residents in the Mission District have been displaced from their community. We all know that the rising cost of living in San Francisco has led to many people being displaced. Lower and middle income all over the city. Because it there is richness in this neighborhood that i also mentioned the fact it is flat and so accessible by trip public transportation, has, has made it very popular. Its a struggle for us right now, you know, when you get a lot of development coming to an area, a lot of new people coming to the area with different sets of values and different culture. There is a lot of struggle between the existing community and the newness coming in. There are some things that we do to try to slow it down so it doesnt completely erase the communities. We try to have developments that is more in tune with the community and more Equitable Development in the area. You need to meet with and gain the support and find out the needs of the neighborhoods. The people on the businesses that came before you. You need to dialogue and show respect. And then figure out how to bring in the new, without displacing the old. [ ] i hope we can reset a lot of the mission that we have lost in the last 20 years. So we will be bringing in a lot of folks into the neighborhoods pick when we do that, there is a demand or, you know, certain types of services that pertain more to the local community and workingclass. Back in the day, we looked at mission street, and now it does not look and feel anything like mission street. This is the last stand of the latino concentrated arts, culture and cuisine and people. We created a cultural district to do our best to conserve that feeling. That is what makes our city so cosmopolitan and diverse and makes us the envy of the world. We have these unique neighborhoods with so much cultural presence and learnings, that we want to preserve. [ ]