Edward a chow, Cecilia ChungJudith Karshmer david pating and all those in favor say aye; all those opposed say no. I have one addition. That would be under the gift report and after the comment on the action taken if you would note that if i had said to the chair that we would be sending these notes to these organization it would then record that we actually normally would be doing that. If that is okay. In addition, i see that we have approved the minutes with the addition and just to be sure all those in favor just say aye, all those opposed say no. You have the directors report in front of you. I want to add a couple of things. We want to welcome dr. Lisa pratt, the director of Health Services many of us know her background and were very excited. She is a certified internist and addiction specialist. She works at the cclinic and she has a position at San Quentin State Prison and she is bringing some leadership to us and we are very excited she has given 2 decades us. I want you to know that because of the weather we have been working very hard with our distort organizations and Human Services and we have several shelters that were looking at for providing for people that are homeless during this time. We have an expansion of our existing shelters. We can expand over 80 to 90 beds they are. We have also opened up some temporary shelters at the recreation centers. I want to thank this weekend eileen watkins, amanda patrick, and there is work being done with the shelter and this is going to be a permanent shelter very soon. We hope that by providingthe shelters we are providing some shelter to the people in el camino. We are meeting on a regular basis to do some planning and reporting and we are also working on the super bowl and trying to repair for that. I will leave it there. I had one concern about the shelters. How long would we maintain the shelters . That depends on the team. We do have protocol as to the amount of rain and also the amount of so these were opening up depending on what these weather conditions are. We will be opening these up this weekend. One concern is our health team of doctors and nurses have found that there have been some people that have not been in the care certain a great opportunity he to share. And this is quite the process to go through and a lot of this is based on the weather and the rain and this is protocol and it really just depends on the availability of the people and i believe these did a great job and we are excited to open the shelters. A number of people have been under this care before so will be interesting to track the people that were put under care and not only is it temporary to help achieve, but this is to help these people to learn to care for themselves. Yes we have a combination of these and once i have a combination of these are be happy to share these with you thank you. Do you have any questions for the commission . I have one about the super bowl. In terms of how we would be able to secure the safety of the public that is there. Either in a Emergency Services were more importantly and not just more importantly, but you notice the Environmental Health, how would the Environmental Health be able to achieve lets say purity Food Products amongst so many vendors that are out there. And, it looks like a huge area that will be available for these vendors. All vendors must have a permit that is given by the department. We already have told them what is not permitted and we have a process of the how we will confiscate burkhart for example. We have had 2 meetings and this is for those vendors that want to get licenses and to refresh them to the goal, and we should be doing that to make sure that those vendors are well. And we will not have any tolerance for unpermitted vendors. Our Health Inspectors are getting ready and are prepared, and we note that they have been putting in extra hours and extra days to be able to assure. So what we also have treated it with the Health Department to keep a lookout for those nonpermitted vendors. [inaudible] i know in terms of if we had a boss issue or a multiple casualty we will have that today and we also have people that come bus people to the emergency room and also, people will not be taking vacations for that period of time in case we have to go into emergency settings if we need to. It will be a lot of people and a lot of activities and for the department, we will be looking on the weekend at our department of Emergency Management we will have our pios at the emergency settings to make sure that the public gets that emergency information. I assume, and i know there probably is some communication needed with these counties because this is a unique well, it is unique because the 49ers are not playing in San Francisco they are playing in san mateo. Santa clara has their networks gullwing but so does the city and over the yearsthere has been some misunderstanding about the counties down south especially when these Major Companies came and made some major impacts and i understand that has been resolved but again, we are the key anchor and in a sense, a lot of people will be starting from here. But not all of them. We will have 200 or 300 buses wow going down, all the way down to some of these hotels and motels, from multiple counties and cities etc. Im sure they are doing some really excellent coordination because in terms of this is something that we want to look at when it comes towards your area and we want to be involved in positive outcomes rather than wait dr. Brown, are counselor is already having these conversations to ensure that is happening. Thank you. Any further questions . If not, thank you. We will go on to the next item please we have a Public Comment. We have mr. Perry light. Mr. Light i will put 2 min. On the beeper. Good afternoon commissioners, my name is perry lang. I am with the American HealthEquity Council and i would like to take a minute or 2 to raise a couple issues around africanAmerican Health. I want to do this to take this opportunity to say inc. You to director garcia and to the department. I am quick to come up when something wrong i think that is part of my job but i also want to come up when something is right and i also want to thank the leadership in the department for all of their help. What i am getting to is the new rsq; the black Health Initiative that is anchored i this commission. And i think this is captured in spirit to what should be done to capture africanAmerican Health. However i have seen this before along with members of the africanamerican community, havent seen those funds be increased. Over the past 5 years they have covered about 1. 9; im talking about dollars devoted to the African American initiative. We are at a Tipping Point in regards to africanAmerican Health. I am asking you to support the riqwhich i know you will do. But i want you to look into your own pockets and make sure that that dollar amount matches our rhetoric. A lot of times you tell a company worried businesses priorities by looking at their budget. What youre looking at is a budget that is truly dedicated to American Health. That is all i had. Thank you. Thank you very much. There being no further Public Comment on the list should we go over our next item . Item 5, on the Public Health committee. Today we had an integrated discussion on our Health Division around smoking and cessation health. We would like to share our revolation that we will be sharing at our next meeting. We will be sharing with smokers at our San Francisco health centers, 48 have been screened and 49 have been screened for care. The Quality Initiative under the departments true aspirations as well as what was mandated by. Within one year, Health Members had increased the screening of tobacco from 48 to 58 . As a whole, some clinics were reaching 9598 . Some other clinics have made significant approvement. If you look at all of the clinics moving forward, there are set goals. We would like to represent this as a wonderful step forward. We want to make sure that everyone that is smoking tobacco is offered a screening and offered a counsel and treatment if it is needed. Regarding treatment and counseling we offer a threeyear plan within each clinic. Once we have identified the person is a smoker, we began some motivational interviewing and upon that we mix some referrals and some counseling and or medication. We do not have the data on the medication jet but the system is working on that. We have definitely seen some improvements with the screening and referral rates. We are just giving time. Currently,we are in the 50 bracket. We are giving referrals for needed tobacco measures. So we wanted to mention that Going Forward. Any questions before i talk about our population curtailed who are smoking . You have any questions for the clinic . Lets go on to our tobacco 21 initiative. We have our community and Health Environment initiative. Smoking is our number 1 healthrelated morbidity and mortality. 14 are smokers and according to the institute of medicine, they just came out with a report in 2015, if the smoking age is raised to 21 we will be able to increase the smoking rate by 12 . This occurred because age 19 seems to be a very important transition age in which people are introduced to tobacco before the age of 19 and they continue a lifelong pattern of tobacco use. The majority of smokers today start smoking before the age of 19. This has a direct impact on [inaudible]in the last 2 years currently, new york, hawaii and santa clara, have raised the age for buying tobacco to 21. You have to be 21 before it you can be sold tobacco to. We are working on an initiative to prevent retailers from selling Tobacco Products to people that are 18, 19 or 20. I would like to conclude that supervisor wiener is in support of the resolution. And we did not have any Community Questions regarding the resolution. Is that part of our meeting at all . I think the health data that we have really supports the resolution. I highly recommend that the commission approve it. Did we have a discussion as to whether the language concluded any Nicotine Products that were developed. We are reassuring what the language around tobacco use is. Do you have any questions about any questions we have raised . Why did we include age 18, 19, and 20. Why did we say those ages specifically for Tobacco Sales . That is because if we said that we would prohibit under the age of 21 sales. Let me jump in dr. Chow. That recommendation should have a specific impact on San Francisco. Thank you because the way it was written it wasnt clear. They just didnt come out and say 21 and up. Now you have explained the legality issues and right we do not want to be in conflict with the state law but this could be in addition to the state law. That makes a lot of sense. Great. Any other questions . That was a very well presented summary of the proposed component. This is an opportunity to see how our Health Commission has been collaborating aand we see this is useful. We see this with Emergency Response and we see this with dental care. Again we are appreciative to both positions because they are very Important Health measures. Any further questions on the report . If not, well move on to our next item please. Our next item is the revolution and support of dr. Pokes solicitation process that will provide a electronic and secure Health Monitoring system that will allow us to enter into secure negotiations with the judge him. Again this is an action item today this is one we would be working to pass today. It is my understanding that mr. Kim, Going Forward towards the board are with this. Okay. Good afternoon, commissioners. Cio for the department of Public Health and before you is a resolution for your action, as stated. It is a mouthful, so i wont read the title. This proposed resolution is for our new modern, secure and fully integrated Health ElectronicHealth Records system. So this presentation that you are looking at, before you and its actually a mirror copy or summarized copy of the resolution before you and i will summarize as opposed to going word by word as im assured you have read the resolution. There is actually two major components to this resolution that were seeking the resolution is basically to in support of the director of health, director of Health Decisions to seek approval for the board of supervisors that the competitive solicitation process will not apply in the procurement of a modern ehr for dph. That is part 1. Part 2 allows the department to enter into negotiations exclusive ly with uc for the ehr system. Part 2 of the second component is if the director is unable to obtain sufficient assurance that uc and dph is able to reach a fair and reasonable agreement within the six months from negotiations, the director may also enter into negotiations with Turner Corporation directly. The next two slides actually goes into some summaries of why we are asking for this resolution. If you would like, i could go over this with you, or if you like, i could answer any questions that you have. . Why dont you briefly walk us through the two items. First of all, the slide recognizes the Business Needs and as you know we have aging ehr systems and we have a need in order to compete in the modern Health Care World for an integrated ehr system, to really better fulfill the dph mission to promote and protect the health of san franciscans. Basically by coordinating better care. The next part is really about we need this system because our Current System does not meet the ability to comply with federallymandated requirements. This also mitigates risks associated with loss of vendor support for our current Electronic Health records system. Which is scheduled to end in 2019, if we have the 2year extension. Why the preferred solution . Why are we asking to negotiate directly with ucsf . First of all, i would like to bring to your attention the Industry Position on ehr, statistics by dhhs, as well as consulting firms, gardner and klas clearly shows that the Market Leader in the ambulatory and Hospital Centers are turner. Why epic . Why ucsf . Treasone of the two ehr systems that can meet our needs, but more importantly brings a benefit to us. During our research we have learned that we have a unique opportunity to leverage with ucsf, specifically the preexisting familiarity by shared physicians and residents will enable a Clinical Care coordination, and Patient Safety across continuum care, not only within dph, but within the two organizations. This will improve clerk clinical implementation and adoption and support because as our physicians and residents would also be familiar with the project and decrease our costs, as well as allow research that well be sharing information with ucsf. That is all i have for that main component of the resolution. Now what i have before you is a timeline. Should this resolution be approved, we are still looking at approximately a yearandahalf before we can actually have the contracting done. Now having said that, it may move much faster, but we dont know at this time, as its very early in the process. But we are going to be doing our best to actually decrease the amount of time well spend in contracting. This timeline shows were planning to add the new ehr system implemented in two phases before the end of our existing ehr support. That is all i have. Bill, if i may . When we talk about we should define contracting because contracting is also the amount of time in negotiations as well. Yes, it is. Contracting the whole process would not only include the paperwork for contracting, but negotiations under very large contract so from the timeline, could you show us or try to point out when the system would actually be until operation and use . Yes. And therefore, what areas of this would be our stopgap support or continuation of what we have currently . Or is this a gradual thing . What colors go where . The goldcolored bars actually represents the implementation and the stars represent the goal life. As you can see the goal life the implementation, as well as goal life actually overlap. By doing this manner, we are actually able to leverage the number of teams we have in order to cover all of dph. We cant do a bigbang, because that would be a huge resource drain on the organization. Now having said that, our current contract is scheduled to end in 2017 our primary ehr and we have an option to extend for two years. So that would bring us to 2019. We do need to have this system up and running prior to 2019. So we could actually run them in parallel and sunset, minimizing the risk of not having an ehr system that is fully functioning. That is not what is on the chart here. Yours is a timeline on implementing ehr, but it does not show; right . The continuation of the current programs that we have . That does not show. Its just assumes that this just assumes when we have to have it in by. So we can continue our existing programs, and as best as we can, meet whatever requirements we need to do while heading for what looks like a july implementation on at the acute and ambulatory. That is correct. Commissioner just a more fundamental question, perhaps. Were choosing epic, is that what this is implying . Yes. And were not only choosing epic, but ucsfs version of epic or allowing us to be under the ucsf . Yes to both. Well be using their version of epic, as much as we can use in our work flow. Okay. So do we contract separately with epic or are we contracting with ucsf . Well be contracting with ucsf. As a subcontractor . Yes. Interesting. Okay. That would include i want to clarify to you is that what this resolution is allowing us to do is negotiate a contract with ucsf. Under their epic contract their epic system to us and has to be agreement with our principal negotiating partner is ucsf . Yes. And the clause that is sort of a bailout clause if everything falls apart . Absolutely as a business plan, we always have to have a plan b. Were going to try to do the first phase and get through that and try to have a positive outcome of that, but just in case we dont have go back through another process that would take a lot of time. We needed to have a plan b. Okay, i assume well have a direct foothold or hand in the negotiations, because its a thirdparty negotiating through someone else, we may not get the preferential rates that were wanting. Well have direct contact with epic in this process . Well be working through ucsf for that. Commissioner. Commissioners, we do have two public testimonies. So perhaps what we should do is take the public testimony and then well have further questions. So that we do you want me to wait . If you would, please. Unless there is some sort of technical thing, i do realize that we have two speakers. So bill, why dont you wait a moment then. Thank you. Let me get the two speakers. First dr. Carlyle from ucsf anddina long. Three minutes on the timer, everyone. Thank you. Good afternoon commissioners. Im here as my position of vice dean at ucsf to speak to you and today im here to strongly urge to support this resolution to allow us to negotiate with ucsf for implementation of epic through the dph system. There have been extensive studies both internally and externally to look at need for enterprise ehr for the dph and there is no question that we need do this. It has also been widely looked at and we have come to consensus that the best way to be successful in the implementation of an ehr throughout the system is not just to go with epic, but to go with epic that is installed on their license, and installed and maintained by ucsf. That is what this contract would include. This would enable a number of things. No. 1, improve Patient Safety throughout the system. As all of you know many of our patients go to other places either because they get sick in other places or because were on diversion or more many reasons they end up in other parts of the system. Having the same system as uc medical center, kaiser, the sutter system and stanford, as well as 80 of the rest of the country would allow us to seamlessly receive and give information on our patients in a highlyprotected manner. It would also decrease costs, because we would not have to duplicate many of the tests, and other measures that we have to do on our patients when we cant get information in a timely fashion. As mr. Kim mentioned we also would decrease costs of training because many of our dph providers both at the hospital and throughout the system, are already trained with epic, either through the Ucsf Medical Center or through other places, throughout the country, where they have worked. Lastly, i would like to point out that almost every system in the entire country that has installed epic has found that they have improved their Revenue Cycles immensely. And in this era of health care reform, we definitely need to do that in our systems as well. So we expect that it would not only decrease our costs overall, but allow us to be more efficient in producing revenue for the system. The other reason is that the uc team has done this implementation a couple of times already, and are very expert. They are actually here today to help us answer questions; and so using them, we would not have to reinvent the wheel. So i urge you to consider this for the safety of the our patients in our city. Thank you. Thank you. Our next speaker, please. Hello imdina long, the Vice President of policy and advocacy at San FranciscoCommunity Clinic consortium. We serve roughly 10 of San Franciscos population with primary care through nine Health Clinics and work really closely with dph and when our patients are hospitalized, many are hospitalized at general and many see specialists at the general. We fully support that the department is seeking the best option for a modern, secure and fully integrated ehr system. Im here to just ask that early on in the process, assuming this goes forward, that the Community Clinicks are included in some of the thinking about how this is going to be fully integrated system . Because we are part of the system. So we want to make sure that information can flow freely back and forth in best, efficient and most protected way, when one of our patient is hospitalized at the general as one example. Many other examples, as you know we have worked very closely with the department on things, like, making the specialty care, primary care referral system much more efficient. So we just want to continue that work, but we feel like instead of an afterthought that the Community Clinics could be considered as an important part of the system from the beginning. And we also just share have a little concern that im sure is shared by others by what is going to happen in the meantime . As you know, we have an aging system, and its kind of creeping along and there has been some particular problems recently. And you know, two years is a long time go with a system that may not be working properly. So while were all excited about having a brandnew system that works better, that we need to make sure there are plans in place for dealing with patients before we get there. Thank you. Thank you. Mr. Kim, i kind of interrupted you at this slide, and the explanation of this important topic and getting into some of the details. Did you have some other comments prior to us continuing the questions . Commissioner, the only comment is that the oneandahalf years outlined in the purple bar below the green seems long. That is for this whole process of resolution, the ordinance, negotiations, contracts, reaching the terms, and signing of the contract. What i would like to add is that well be doing our best to shorten that timeline. However, at this time, we do not have it is a very large contract. I will take any questions that you may have. Okay. So well go back to commissioner taylormcghee. Thank you. Thank you for your presentation. I dont have to say this is a really an important decision to make. So having said that, what is paramount in the decision to forego the competitive process . Is it time and cost . Is it market availability and capability . What would you say is more paramount . Well, actually im glad you asked that question, because that is the decision that we have been the question we have been asking for some time. Obviously there is always a question about affordability. Can we afford it . Because in reality its not only about putting the system in, but supporting it. I think even beyond that the most important thing what has to ask of something of this magnitude in terms of investment is how successful . And will the organization be using this new product . What value will we get out of it . When we look at the partnership that we have with ucsf, one of the things that we know we had over 100 years of relationship. Having said that, we also have many physicians and many patients that go back and forth between. We actually would benefit significantly, benefit the city, if we can share that information seamlessly, as opposed to just sharing a toplevel basic patient care information. So i think there are many benefits to partnering, but the most important benefits that i see is the ability to seamlessly integrate between the two partner organizations. Which we cannot have if we went directly with epic, it would be difficult, and not as easy. If you went with any other vendor, it would be the same situation. Thank you. Commissioner pating . First of all i want to lodge a complaint that a topic this big, im not sure i feel like were getting an adequate briefing. There has been lots of issues that we have looked at over the last six months in terms of cost, quality, amortizing out and im not sure if i had to complain this to my grandmother why epic was chosen other than ucsf and in terms of cost and quality and other things that we looked at and when you weigh against turner, what were the major issues that stacked up . Because cost was driving a lot of the conversation before. And now you have settled here. So im just to me, its a question that we should have spent a little more time with a little more data in preparation. So its a little bit similar to what is what commissioner taylormcghee is asking, really looking for other than ucsf likes and the integration, but feasibility . Who is going to maintain this . Is it going to be your staff . Ucsfs staff . If ucsf has a problem with it does it affect us and the issue of coalition . There are lots of dinner different questions on something this technical. If you would like, i could answer those questions. And how you make the best of basic decisions of epic versus turner . Would you like me to at least try to answer those questions now . Yes, please. We spent i would say approximately 2plus years looking at various options in terms of researching. We needed to understand what system was out there that would be a good match for us . A good fit . We know this is a onetime deal. You dont make decisions like this twice. Its a multihundredmilliondollar project. When we looked at the products out there, doing the research, we looked at the industry leaders. Not from a vendor perspective, but we looked at the independent researchers, that looks at the quality, the performance, the support, the ability to implement, but more importantly, ability to deliver on promises. As well as future vision of their product. It was very clear that only two Major Products that actually existed in the world. There were epic and cerner. Having said that, they both have different boists benefits and this is without ucsf in the picture that im speaking of. Having said that, we actually went to Industry Analysts and asked, what are the key components that will allow you to succeed or fail in such an endeavor . One part is that you underestimate your own internal it capabilities or you overestimate it. Another component that allows you to fail or succeed is the rate of a doption. How willing is your organization to adopt this administrative massive change in the organization . Those are two major key criteria and looking at failed and succeeded ehr implementation and adoption, those two items always come up at the top. The reality, these two vendors are very highly regarded and these solutions have been around for a long time. The question is which one is actually the best fit for us based on current it infrastructure . Current it support model . And our budget . And our physicians ability to absorb yet another ehr system . On top of that, we asked, what ehr system would be reasonable in terms of datasharing across california and we did not ignore the fact that epic has the largest share in this area. If we intend to share patients through ed, or through specialities, we have to take into account that we are going to share data and not sharing data at the highestlevel in very basic summaries, but in detailed diagnosticlevel, so we could avoid costs, but more importantly provide information readily to the physicians so they can take action. When we looked at all of that, withless r with the ability of our physicians knowing very well how the system works and the proven track record of the ucsf team and their ability to implement, which they have already done several times outside of their own organization. If you stack the pros and cons of the solution, which would be most beneficial to us, but just as importantly, which would be the largest or which solution would have the most mitigative factors in terms of riskmanagement . Because at the end of the day, if you choose to buy a solution that will not be adopted by your physicians, that they will have challenges, because now they are being asked to learn two different systems or more importantly that the work flow is completely different than what we are used to. And its at the highestlevel as opposed to detaillevel. You have to ask are we buying the right product . That i believe is actually, least in terms of my team, and the leadership, one of the biggest questions we constantly asked and reasked and we came back with the same answer. This is the right solution for us. I hope that answer yours questions. If you need details how we got that, as you know, we looked at financials and modules and support modules in detail. Could we take a moment to hear about the Financial Investment . I was going ask if mr. Wagner our cfo could describe how he feels this is a viable Financial Product for us . I would just like to add, that were going into negotiation so select. Right. So we have not selected yet. This allows us to go into negotiations. So some of the questions you were asking about how this is going to work, that is what is going to happen in our negotiations and well be bringing some of those concerns and updates to you as we go through this negotiation. Those are still concerns on the table and this would be to allow negotiations without a Competitive Bidding process. And on that, also, we might look at how long would our Competitive Bidding process take if we had to do a competition . We reviewed that and we would be very late. At this point we already did that timeline and it would put us out of the park in terms of not being able to meet the timelines, nor the continuation of our systems. So in essence, either way, you would actually be asking you came out with wanting to negotiate with epic, but you would really be asking for the ability to waive that because of our time constraints at this point . Correct. Yes. Mr. Wagner, please. Craig wagner chief Financial Officer and my initial response will be as barbara said, we not have contract and were asking permission to negotiate a contract and financial terms will be part of that negotiation. As bill indicated we have done quite a bit of Industry Research leading up to this moment and tried to look at some of the costs. We do believe that we are in a place that we have a financial strategy, where we can accommodate this course forward and would not do it if we did not. Some of the major factors involved is what would be required in any scenario in terms of our internal staffing . The issues there are the costs, but it is also our administrative capacity to rampup at the level that we would need to, if we had an internalintensive staffing process and that leads to another factor that bill mentioned which is financial riskmitigation, that has do with our ability to deliver the product efficiently, and ontime. And also, our ability to have a stable, Financial Model for the maintenance and operation of that product other issues that factor in this raised earlier is our ability to leverage Revenue Cycle capability from the product, and lastly, our ability to potentially leverage philanthropic dollars to support the project. And we think that there is a likelihood that given that we have some of these kind of cuttingedge patient care advantages that we can get out of this system, that there may be some philanthropic support that we can bring in to help improve the financials on the project. So we have spent some time. There is more work to do on it. We have had two outside consultant engagements to do some research and give us some thoughts of what we should be expecting orders of magnitude and were at a point that were comfortable that we have a Financial Model that will allow us to move forward. We have been working with the Mayors Office, and the Controllers Office on what that looks like, and how we fall into the citys fiveyear financial projections . Thank you. We do have another public testimony which i will take at this time and then well continue with our questioning. Our chief of staff at sf general. Thank you, commissioners. I will be brief. So clarifications of reasons so move forward with this resolution. First of all is quality and safety for the patients that we serve. As commissioners chow and karshmer are aware our system pose safety and quality issues for our patients and we need to get an integrated system and we need to move with a sense of urgency and we cannot wait, which is why we need to move forward with the sole source process and in addition, to the quality and safety point of view, all of the hospitals in the bay area, that our patients end up were on epic, a compelling reason to have the same ehr system and the second point i would like to emphasize what bill kim said. Were about to undertake one of the most expensive journeys and most important tasks that the dph will face in the next decade. We need to get it right. We wont get a Second Chance and that requires moving with a vendor that has done this before; that has the Technical Expertise to make it work, and that can compliment the expertise that exists within the dph. And as mr. Kim also said, getting the providers onboard as has been shown, probably the singlemost important thing other than having the expertise, that determines the success and then implementation. 18 Service Chiefs at San Francisco general have all gone on record as supporting implementation ucsfs instance of epic at the dph. Doing an implementation is extremely challenging even with everyone onboard. Doing it under other circumstances will only make it more challenging and increase the probability of failure. Thank you commissioner sanchez. I just want to say that is really an unique opportunity for the department to move forward. We are not tonight we are not approving the contract per se. This is a continuum with a specific block of time, so we could come to integrated consensus to move forward. The uniqueness of this, there are many positive outcomes, because of the affiliation. No. 1 our patients are seen by ucsf partners, et cetera, et cetera. They have already been trained in a number of these pathways pertaining to records, et cetera, et cetera. There will still a number of things to be worked out because we are a city and county and we are a department . Yes. And over the years we have sat with our partners at ucsf pertaining to unfortunately suits, because of different issues involving both the department, or sf gh or laguna honda or the regents and it takes a lot of work and understanding. All im saying is Due Diligence and patience and the director is asking for a resolution to proceed on, and to negotiate. I would hope that we would not just look at the positive outcomes,which are more than substantial, but you know, there is also, perhaps, some areas that we need to be aware of that might be under the radar because of this. Im sure ucsf has thoughts and the regents have thoughts and the city and county and so on. Its going to take additional discussion and i look forward to the recommendation from the director, hopefully at the 6 month period or before then. So we can move on. Because this is a key, critical part on how, in fact, were going to provide comprehensive integrated services. This isnt just for sf gh, but laguna honda and its our benchmark, but we need to have the final package brought for our approval, to have full public discussion, and vote it out when the contract is presented. Right. Commissioner, you are right. I just want to echo what has been stated before. This is not to have you approve the contract. We have much work to do. We would at least need six months to come to terms and agreement as to what the basic shall i say showstopper issues have been addressed . Even then we expect another six months to get the contract done. We are far from reaching the end of the road in terms of implementing. This is just for us, dph director asking may we move forward . Because when we looked at all options during our research, this seems to be the most viable. As commissioner taylormcghee has stated she asked about the timing . Yes timing is an issue. We dont want the timing to drive what decision we make. However, time is an issue in this situation. Now is timing such that we cannot we dont have any other option . The realitis, we do have other options. Okay . But it is for the benefit of dph and the city, for us to take the right decision and move forward, as opposed to wasting or spending another year or two years spinning the cycle to get to the same conclusion we already know is inevitable. Just to be clear about the resolution. It is asking to you support my decision novforward on this. I do have authority in the contracting process and im asking for your support of our decision. Correct. Dr. Pating and commissioner taylormcghee. Im trying to get a narrative, so again, when i go home, i can sleep tonight around this. Director garcia, you always have my support. So you dont need to put it in a resolution. Im look at four factors, quality, cost k feasibility and integration and im hearing either way were going win with this. Feasibility you worked out a really elegant solution that saves staffing, effort, time, and i just really want to applaud you on that. Thank you. To hear mr. Wagner on costs and then hear you on integration one more time. Yes. The last episode and i dont think i have missed any tv shows here, my recollection on cost were worried about a 20 million a year amortization that we had to keep paying out kind of indefinitely and with the cerner product was going to be smaller and tradingoff cost and quality. What happened to the gap . Have you closed it enough . Im pleased that the mayor is weighing in and feels that you have done good work here, but im still in the last episode we didnt have enough to pay for the product. So [kwhapd ] to what happened to that . Thank you, commissioner. As you know, its been a long process this. Is a heavylift for the department to figure out how were going to finance that and that is indifferent to the solution that it is. So we have been doing a lot of work and again, i want to emphasize that we are asking for the authority to negotiate the contract. And so the actual cost will be depending on what were able to negotiate. If were unable to negotiate something that is to our financial satisfaction, and fits within our Financial Model, that will be one of the criteria we use to decide whether this can go forward . That hasnt gone away. Its still there and were trying to work with it. There are a couple. Again, a couple of factors that are mitigating factors. So you have as you look at this, you have the cost of the contract that youll have for the system. And you have the cost of your staffing that will be required, your internal infrastructure, that will be required to support it. You have the cost of training and cost of physician adoption and your relationship with your physician model. Again, in this particular case, a significant factor is what we may have access to in terms of philanthropy and fundraising. So with all of those factors put together, when you look at this at the end of the day, we have seen in the studies that we have done and also in the research that we have done, independently, that there are different ways that you can look at the cost. Where one is higher or lower in the shortterm, but over time, the general consensus is that on an order of magnitudelevel, that they are comparable costs once you take into contract and internal staffing costs. There has been estimated gap that we have looked at and that has been moving over time. But we do think a couple of the significant advantages that we can leverage through this approach are what we can generate in terms of revenues . What we can general in terms of philanthropy and riskmitigation of not having to start fresh with our own internal costs and our own internal risks associated with building from scratch. By leveraging the ucsf build, we can get a significantly cheaper product than if we actually went to epic directly and built it ourselves using our internal staff and hiring contractors. So there are a lot of moving factors in the analyses. We have thought about it very closely, but again, i have been one the people who has been very wanting to take a very cautious approach to make sure that we have the funding model in place that we believe that this is at the point that were ready to move forward. And i do think that we are at the point where we have got a Financial Model outlined that makes the potential pathways comparable financially. And where we have a quality and a patient care and a Public Health benefit from leveraging the partnership with ucsf. Again, we will be negotiating the contract with the financial terms, and we will negotiate we will not accept a contract that ends in a form in such a way that does not fit with our Financial Authority within the budget. And within the citys 5year plan. That is very, very reassuring. Thank you very much. Mr. Kim, last question. With regards to the thing uc is a little more integrated, more centralized. Were very dispersed, as well as we have a lot of contract facilities with Mental Health contracted out and consortium, our partners. How do we integrate with that . Are they responsible within your model or are we responsible for providing the desktops and linkage and Technical Support . From a technical perspective, i think i would like to go over approach it from a highlevel. First of all, what we will build based on the current ucsf ehr is going to be built with our partners in mind, not just ucsf, but everyone that we work with. I think that has to be foremost. For this to be successful for dph, all of our partners leverage our ehr system has to be part of the equation, okay . Having said that, one of the benefits of choosing this solution is that is twofold, epic is the prodominant leader in this area, making information going from one organization to another much easier to accomplish. But more importantly, ucsf also has partnership with other organizations that we may be interested in looking at their data from a Public Health perspective. Now all of this has to be negotiated, and reviewed. But i think the opportunity is very unique. I hope that answers your questions. Sounds like the partners will be brought in early and at the groundlevel. In our governance model and when we designed this, we are actually even including a group of patients to be part of the governments model. So they could help us build the patient portals. Were not going build this in a silo. Were going build with all stakeholders, including the patients in mind. Commissioner taylormcghee. Thank you very much. I want to thank bill kim, and mr. Wagner for answering the questions. It for my clarification, i just wanted to say, this is what i got out of what you said, okay . This is compatibility with the market, making for a greater opportunity for seamless integration, Patient Safety, thorough cost analyses, and also, easier to adopt with the current it system. I think the other one that was important is timeliness and urgency. So given what you have said, i think it makes sense for me. Im comfortable. Commissioner taylormcghee, i would like to make one tiny correction. Sure. The adoption is not most technologies today, the 2 ehr, 3 ehr vendors at the top of the market we can adopt them, but the question is how much burden will you put on the existing users . When we look at systems, most it folks will look at how great the system itself is, without thinking that the system must include the endusers. The question is if you were asked to drive i just learned to drive a manual stick shift gear that i will use an as example. If you already drive an automatic car, and someone came to you and said you are going to have to add another car to your family and why dont you just get a manual . Now you have to drive an automatic and a manual. Would that be much easier to adopt and troublefree as opposed to getting another automatic or visa versa . If you already had a manual, would you get another manual . I think the burden in this situation to the physicians when they taking care of patients in a trauma setting to learn a brandnew system and expecting them to be effective and efficient from the getgo could be very challenging. One of the Biggest Challenges i have seen is an organization trying to get to the value, dollar per dollar, out of a system, arch after they have just make this gigantic investment, because they are being asked to add another Technology System to their belt. Both of those cars are safer than your motorcycle. I have gotten rid of my motorcycle, director pating and drive in a very save, airbag surrounded car. We are very happy for that. Both of these Computer Systems are better than what we have already. I think that we all agree. I began to envision airbag as round your motorcycle, but that is okay. Commissioners i think you raised all the issues important in the process of negotiations. Again, this is a resolution, which for those who have read the first iteration of our agenda, looked like we were going vote next week, but, in fact, the final agenda indicated that today we will do the voting. So that our director has our support. If we choose to offer that support, in order to begin the actual negotiations for all the reasons that i think we have heard. Least from what i heard is timeliness, discussing this issue for many months, if not years, and the very careful and very prolonged process that has occurred in doing vetting of all of the different systems, and the advantages and disadvantages and the abilities to really articulate why you would then like to move forward, not only with the waiver of a competitive bid, but with a specific system that has all of the advantages as you see it that would allow much quicker adoption at a lower cost. And with the understanding that the department feels that having worked out with also the administration, that these are doable. I think that that is where we are at today, if the commission will remember the questions as obviously the contracts come forward. Those will have to be answered. Commissioner chow, would i like to add that were not asking for a waiver, but onetime exception ordinance to the city administrative code. And we also need board of supervisors approval. More formally, the competitive solicitation process. Be waived . Yes. Onetime wafer. I would go ahead and move the resolution. There are some typos on page 2 that i think are easy to correct. Again, im reading the story as Higher Quality at comparable costs, which i think is a good tradeoff here and [ 3450ez ] when you present this to us in the future, remember what we are asking, because i think it would have been presented with the factual basis that we needed to help support the resolution. We commend you on your work. We appreciate that, commissioner. I heard a motion and second from commissioner sanchez. Do we have any further discussion . If not, were prepared for the vote. All those in favor of the resolution in support of the director of healths position to seek approval from the board, from the competitive solicitation process, for the fully integrated ehr, please say aye . Aye. All those opposed . The resolution has passed unanimously. Thank you very much everyone. Thank you. Thank you, commissioners. Item 7 our next item is the San FranciscoHealth Network update with the pharmacy update. Thank you everybody. Good afternoon, commissioners. Roland pickens director of the San FranciscoHealth Network. So its my pleasure this evening to provide you with this update on the development of the network. My goal today is to share with you some of the key tasks, and focus areas we have undertaken over the last six months that will help shape the evolution of our network in the coming years. In my presentation today i will not revisit our previously adopted wayforward measures which we reported on. As you know from our last report, most of those initiatives, those measures were actually achieved, and we sunset those in june of 2015, which was the end of the first 18 months of the networks lifecycle. Instead today, i will focus on key Strategic Initiatives of both the network, and department, that will help us transform our clinical Delivery System into a highfunctioning care organization. After i have finished my presentation, ill be happy to answer your questions and receive your feedback. At the conclusion of that process, i will then invite to the podium dr. David woods our dph director of pharmaceutical services, and he will provide a very brief overview showing the organization of pharmaceutical services across the network and the department in order to give you a more tangible example of our ongoing efforts at integration. So in terms of the first area of strategic visioning for the network, as part of our overall dph initiative to spread the lean Management System across the department, the San FranciscoHealth Network conducted our first strategic visioning session utilizing the lean methodology. In september 2015 over 30 staff from across the network and the department along with commissioner pating came together and utilized the lean methodology to establish the three most critical strategic pillars to guide the development of a network and those are our mission, our vision and our true north and its true north metrics. After much deliberation, we reached consensus on our shared mission, vision, which you see before you, our mission col that we provide highquality health care that enables all san franciscans to live vibrant, health yip lives and to be first choice for every San Franciscos health care and wellbeing. While most of us are familiar with develop is recommending an Organizations Mission and vision statement and the idea of developing a true north was a new concept for many of us. We first learned about the concept of true north when we visited the Health Care System in wisconsin. Theta care is wellrenowned for being one of the most Successful Health care Delivery Systems to adopted lean methodologis to drive operational efficiencies. Simply put true north is that small set of goals which can be articulated by everyone within the organization that represents the organizations unwavering and highly focused commitment to fulfilling its mission and vision. I emphasize small set of goals because true north is not meant to envision to encompass, nor replace the hundreds of projects and initiatives, metrics and dashboard reporting processes that occur throughout all levels of the network. Instead, the beauty of our network true north is that its succinctly identifies those key goals that the organization has committed to focus on above all others. In in addition to our network true north, each division in the network has already or is in the process of finalizing its own true north statements and areas. Currently we are working to, as much as possible standardizing these metrics across the network. You will note that our true north goals allows the network to be aligned across our divisions, while still allowing each division the flexibility to tailor the melt metrics to their specific needs. In the back of the documents we provided to you, you have a draft showing not only true north of the network, but also some of the proposed true norths of the various divisions. For each true north goal were developing no more than two metrics, monitoring the progress towards obtaining those goals and we will be reporting these on a quarterly dashboard. In order to finalize our network true north metrics and develop our implementation plan, or what is called the x matrix and lean Management System, well have our second strategic visioning session march 89 to finalize that and well report to you in our next update. In addition to strategic visioning, we have focused a lot of our efforts over the past 612 months on our strategy of managed care. You will remember that in 2012, the Health Readiness assessment by hma made the recommendation that in order to ensure the Financial Health of the dph Delivery System, we would need to increase the number of patients within our network. In next few slides, im going focus on two of the tactics recommended in that hma Health Readiness report. The first tactic is the growth of our Patient Population served by the network. The tactic asks that we consider securing additional commercial health plan contracts in order to increase our Network Membership and the second tactic to initiate a de novo Outreach Marketing and branding for our network, something that we have not done before. In order to move forward with these two tactics, we have already started that process, and the two specific outcomes. First, we have developed a plan or roadmap for showing how were going progress from having only medical managed care contracts currently to having commercial and other valuebased payment arrangements and contracts. In this regard, we have worked with an external consultant to develop our managed care roadmap, which you see depicted in this diagram. It shows where we are today, and starting with 2015, only having a medical managed care contract, and showing progression over time, based upon the consultants expertise in terms of how can we build a sustainable system to support managed care contracting . Knowing its something that you cant turn a switch on and go from no commercial contracts to commercial contractors overnight. So in order to lay the groundwork for successful entry into a more robust managed care environment, the consultant engagement helped us identify a few key foundational infrastructure elements that we must have in place in order to be successful. And you see those listed here. The first we just talked about, which is having an enterprise Electronic Health record. The second is organizational intelligence, which is a proprietary software, which is a Cost Accounting system that allows us to cost out services particularly at our acute Care Trauma Center that we will need in order to set contracting rates. The third, which is Network Operations integration, we have several systems throughout our network that are not integrated. As you know, we have a separate medical staff or the at San Francisco general, one at laguna honda and separate credentialing process in Behavioral Health and from a planned contracting perspective, were going to need to centralize and coordinate those functions so that what dealing with payers, there is a onestop shopping as opposed to having go to each entity to provide that information. That is one key finding from our consultant engagement. Finally our network branding and marketing process. Again, this is something weve never had to market our services before. We have always and continue to take all comers, but if were going to increase the number of members in our network, were going to have to begin to market ourselves. Im sharing this next slide with you in order to give you a perspective of our current environment in managed care. Which as previously mentioned at this point is only limited to medical managed care and of course, that excludes our programs for healthy San Francisco and healthy workers. You see the numbers here. The San Francisco population of that 848,000 population roughly 170,000 plus have medical and majority of which are in a medical managed system through San Francisco system or Anthem Blue Cross and our network of the 150,000 managed care lives has about 62,000 to 63,000 in our network. So in this slide, it shows our planned trajectory based upon consultant engagement for expanding beyond medical. For sustainable, you remember sfhn will need to increase your patient base to 90,000 patients. Im going to go back to the previous slide. That last number 62,000 is what we currently have in our network and we need to get up to 90,000 per the hma report in order to be financial sustainable and final financial viable. As we move to increase from 62,000 to 90,000 in the case of 618,000 san franciscans who have commercial insurance, according to the consultant report, we need to have 1520 of our Overall Network population, which again, that goal is 90,000. Come from those commercially insured. So in essence, we need to attract somewhere between 13,500 and 18,000 of those people with commercial insurance into your our network. A little bit about our marketing and branding. Just as we have done a lot of work in the area of managed care and increased our effort related to marketing and branding and we were fortunate to have a Mayors Office fellow assigned to dph, to develop and begin implementation where feasible of a network markets marketing and branding plan. This next slide gives you a summary of some activities underway and the priorities for next year. That marketsing fellow came on board in october and has been very active in learning our network. Has conducted several focus groups, including key stakeholders, patients, staff, and other systems. And has really helped us be clear about some of the steps we can take now, but also a plan that will be in place by the time that fellow leaves us in the fall of this year. Weve set some shortterm goals in terms of a pilot, doing some promotion of a San Francisco birth center with the obgyn service at sf gh and pursuing contractual relationships allowing for additional births at San Francisco general and do the appropriate marketing and branding to go along with that. We continue to be in negotiations with Chinese Health plan regarding covered california contract, which is considered a commercial contracted. We will need to do the appropriate marketing regarding that contract when it comes to fruition. So from a market point of view, we have three key goals. We need to find new members, enroll them and retain them in our network. And we need to make sure that we deliver a Patient Experience that encourages people to continue to allow our network to serve them throughout their lives. In addition to finalizing our Strategic Plan, and focusing on our true north, there is still multiple other efforts and initiatives that demand our attention and engagement. You see some of them listed here. You heard today that we brought on board our new director of General Health. As know were currently recruiting for ceo for zuckerberg San Francisco and looking for appropriate leadership in our Behavioral Health system as we have Senior Leadership being ready to exit the organization. We have got to open the new hospital. Were going to have a big part in the Electronic Health record, its will be the core of our clinical Delivery System and we have also got spaceplanning to do particularly throughout dph in terms of what is going to go on with our space, and facilities at both laguna honda and San Francisco general. So both priorities also present challenges for us. Obviously, we have a challenge that we must be mindful not to be impeded by overtasking our resources and staff on these multiple endeavors. And its our hope that through using the concept of true north, well be able to galvanize our staff and have one guiding compass in terms of what were focusing on. And finally, just to let you know, that in the midst of all that we are doing, with true north, managed care, marketing, and branding, we have not lost sightful our continued commitment to integration initiatives across the network, and dph as a whole. You see many of them listed here. Our enterprising mr, the continued development of our Business Intelligence unit, and our data warehouse. Our call center expansion, which is one of the major recommendations for implementing expanded health care contracting. And we continue to integrate clinical services. You are going to hear specifically about pharmacy, but Skilled Nursing and rehabilitation across the network. So that concludes my part of the presentation. Im happy to take any questions you may have, and or feedback. Commissioner taylormcghee. Thank you very much for your presentation. I just have one little bitty issue that i would like to sort of point out in terms of your branding and marketing strategy. I would just be careful to make sure that you dont promote yourself as a quality provider for private people, particularly private insurance and i would just shift it to maybe think about it as successfully merging the network as a quality provider for lowincome and uninsured residents. And private people people who have private insurance. Because sometimes you can sort of shift the focus, and then you lose people that way or people begin to think im left out, you know . Absolutely. I just want to make sure. I appreciate that and that was a long topic of conversation within the leadership. We struggled with how to phase it . And part of the discussion was that rather than were definitely not changing our mission or our population, were just expanding it to include others. Right expanding to include others sounds good. Its the same concept. Commissioner pating. First of all, mr. Pickens, congratulations. This is just leaps and bonds the report is leaps and bonds over what we heard last year in terms of our Business Planning and sense of focus, and all the oars rhoiing in rowing in the same direction. I love your mission statement. Its the highlight of my year and i like the areas of the business development, the six domains. The question that i have and most concerned about is your statement that we need 90,000 new or 90,000 enrollees total, 28,000 new enrollees to become financially viable. Could you answer for me what you mean by financial viable . If we dont get that what happens . And the second question is 28,000 people is a lot of people. How do you enroll that many people . So ill answer that by saying that number came from our hma consultant engagement and Health Readiness report that you can find on the city controllers website. What it said, with the growing reliance of the department on the general fund, that the department needed to look for other sources of revenue in order to decrease that reliance on the general fund. And the way to do that was to increase the patients receiving care in our network. And with health care reform, and the move towards more managed care by and large that means moving towards contracted arrangements, where you pay in advance for the care of the population and incentivize to keep them healthy. That was the consensus of that report that we needed to have 90,000 patients that were generally responsible for, coordinating their care, in order for enough revenues in our coffers to keep us financially viable. So again, thank you very much for that. The idea is that to give 28,000 as the context, that is nearly double of what were doing now. Or nearly 50 ; right . Right. So we have to grow some 4050 . Right. That 60 62,000 that you see, predominantly includes people in a managed care type of arrangement with the network. It does not include our feeforservice medicare patients, we have probably another 15,00020,000 and when you begin to add that, it makes the leap to 90,000 a little less daunting. I see, so just people that are already accessing our system to get them to convert, or to stick with us, is that what you are saying . Right. As opposed to new people that have never touched our system . Right. So its always a challenge when we present our numbers, because our patients are in different buckets and sometimes they overlap. There are some that are specifically on capitated arrangement, i can through through San Francisco health plan and medical managed through anthem blue [krosz ] this are actually feeforservice, but we manage them as we are their primary provider. So in essence, another way to think about it, we have 62,000 people in the managed care program, including healthy San Francisco and includes healthy workers and have another 15,000 to 20,000 medicare feeforservice and means we need another 15,000 or so thousand. That is more comfortable and with regards to the risk make up, following up on commissioner taylormcghee, it would be wonderful to have everyone healthy and know that is difficult. But also, if were assuming the risks viable these are people who are already in our system. So its people that were kind of comfortable, down the middle already taking care of. That is what im actually seeing you in terms of the risk profiling . In terms of new populations . Yes. Well, we will continue to focus on the traditional underserved and in terms of that 618,000 circle, those are people who currently have commercial insurance. Who one would think would be healthier than our traditional population and could perhaps be a benefit in terms of bringing in additional resources. So my last comment, and this is not a question really. We might want to look the at where our competitive advantages are and certainly zuckerberg General Hospital that is best in the country and looks great and will be great is a competitive advantage. I know that we have many, many others and were citywide as opposed to some vendors in the city are more localized. One area versus the other. So we can serve and wide catch. I would be interested in the future of hearing how we promote our many advantages as a Health Care System . Absolutely. That is part of the 35year Strategic Marketing plan that the fellow is working on and will present to us over the next few months. So well definitely be sharing that with you. Thank you very much. Commissioner sanchez. Its an excellent report. You really covered the waterfront as you read through it, that is what were really doing and not just in reference to facilities, but in reference to how patients are treated and how were going market them in future pertaining to quality of services. Quality of services that we are still achieving some areas and we heard in earlier presentation about one key critical pathway will be when we have integrated medical records. Hopefully we look forward to the directors recommendations, because i think that is part of the achilles heel and to see sometime in the future not now, but if we could sort of having an overview of the continuum of patients flow . Are we losing patients in certain areas . I. E. , va . Veterans . Are we losing nativeamericansin the Filipino Community . There has been a lot of movement about families being moved out, et cetera. Dadada, what impact does that have pertaining to the cohort and hopefully with the medical records and others when it finally gets aboard, that will be even more of a thumbs up. So we can identify our Patient Population and flow unwhy and sort of like the noshow show appointment. Always of these things its not a critical part, but i think it would give us a little bit insight pertaining to how we sort of navigate the ship as we move forward. Yes, that is our office of primary care is working on so each can see who are the people coming in and going out of your particular clinic . And are there anythings that we need to do to address any particular negative turn . Great. Thank you. Thank you. I also want to commend you, and the Health Network for really developing a comprehensive strategy. That within the short year, as commissioner pating pointed out, has really flushed out where you are going. So my comments are more sort of tweaking a little bit. And most of it is sort of reflected on the payer strategy. I am concerned that as commissioner taylormcghee had pointed out, i think we dont want to be in a compete not competitive simply because its competitive, but starting to look at different marketplaces that may not help our total mission as such. And i think that if you got it from report that we should be picking up 1520 of commercial members, i would like us to review that a little bit more. Because you think when you came down to the numbers and understanding its not really 26 of 618,000 that you need. So these need to really be more carefully thought out and also be focused upon the people for whom we actually are the final arbiter and not because we are the last, but were the best; that these people want to be part of our system and want to find a way to be part of it. So our market can reach this, if that is the final viability of 90,000 or so, easy from being the best within the covered california area. Which i think is even a better marketplace for our type of services that we offer. And and then one reason for being careful is that some of the commercially insured have an expectation different from our own expectation in terms of our patients, and are often then handled in a different way. You may then find yourself spending a lot of resources to do that for a small segment and not really be sure that our resources are going for those who are really our core, that we need to be sure to be able to care for. Its sort of classic for a lot of types of plans that have begun with a focus on a particular, either population or need. And then as they expand, suddenly becomes so overexpanded that they are beginning to try to reach out to different areas and before you know it, you are kind of finding that you are pulling back again. Right. I think the expansion a few years ago is a very good example, in which they tried to also go to over to a hawaiian market and what was distracting to them in terms of their core mission to serve the San Francisco bay area people. I would suggest that trying to work too much on the commercial members versus your other three groups, could be a use of resources that may therefore then detract what we can give to the bigger group. And cover california may 80 plus percent subsidized and a population that we really have an advantage over in terms of types of services that we offer, versus the other commercial plans in the marketplace. If you need to pick up, like you say, its not 1520 , but might be a portion of that covered california. I think that is much more of a viable market. But obviously this is just merely a suggestion coming from our knowledge of where we are, and trying to be sure that we focus our resources to be sure that when we do Patient Experience, and so forth, that we actually put that effort into maybe multiple call centers that we need. Absolutely. Rather than somehow setting up a Wellness Center in pacific heights. Those are extremes, but i would really like to see that we focus our resources on the people who actually we are trying mostly to improve their life. Absolutely. And that is what we are doing. You are right on target. And let me be clear we are by no means ready, nor well be ready to do fullboard regular commercial contracts. The roadmap as laid out shows covered california is our first major one to go after. So as you know, we have been focusing on last two years and hopefully well wrap that up this year. As the consulting engagement, well have to do a small test of change and allows us to test the water. There is a whole series of infrastructure we would have to set up to be able to do commercial contracts. As a very small item, smaller, i would say its not a 35year issue of providing centers of excellence care. Because there we can reach out and we have excellence in Palliative Care and hospice care and rehabilitation, along with some of the specialities at general that are known or trauma of course is also. So i dont think that is a 35 year thing and you could seen sell centers of excellence today. Im fraid afraid, if we dont start looking at where our centers of excellence are, rehabilitation ating at laguna we are in discussions with other systems as to how we market our centers of excellence to their system, where we have that expertise and they dont. Thank you. Commissioners, if we could go on to the pharmacy. If you could keep in communication with us and coming back to us and the Corporate Identity of the Health Network and as we get closer and closer to honing in on what we are trying to do, i think this conversation with us is hopefully helpful to you and its helpful tos us. With the safety net, and safety net plus, maybe we can involve i think if l. A. Cares as a model that has really made a market in serving public sector, but based on financially viable. And i visited the hall and i cant say enough good things that for me it on directors garcia test, would i want to receive my care my familys care there and i would say definitely yes . Its a warm and welcoming place and yet, how we capture this as a Business Strategy is, again, i think its an evolving process. I just want to commend you on it, but keep bringing it back to us as we keep having these conversations. We about definitely bring back the marketing and branding back to you. Not just external marketing, but internal marketing. Absolutely. How we envision ourselves in delivering care. Sounds like im hearing a need for a presentation on our internal external marketing . Whenever you are ready. Dont rush it. Shall we proceed with the pharmacy integration, which i think you are pointing out is an example of how you are moving into being a system. Yes, that is correct. For certain of our services. Okay. Good evening, commissioners. David woods, chief pharmacy officer. Im here to give you a brief overview of integration of Pharmacy Services. Pharmacy began at integration work more than a decade ago with something that was called the chn pharmacy council. At that time the main point of that group was to really align formularies. And this has evolved into something much for than an alignment. The integration of Pharmacy Services is within pharmacy and then we have dottedline reporting to executives at each of the major sites. This ensures operational alignment, as well as ensuring that the sites get what they need from the pharmacy staff. If you look at our budget, as a group, pharmacy is budgeted for more than 50 million annually. We have a dphwide budget process, so that we actually do one budget submission for dph Pharmacy Services for all our pharmaceuticals. This ensures that we do basically a lot of data factfinding look at National Trends and our own trends to put together what we think is the best possible projection for the coming year. Were constantly look at costs, and how we might be able to utilize drug more effectively to reduce costs . One of those measures is with the Patient Assistance Programs. As you can see from this slide we have over 7 million that we saved last year through the use of free drugs from drug manufacturers in the Patient Assistance Programs. We have 1. 5 ftes of pharmacy technicians which do nothing more than help patients enroll these free drug programs for manufacturers. You can see its wellworth those ftes that we have put into that program. We also have a position called the formulary manager, clinical pharmacist, whose main job is to oversigh see the drug program for healthy San Francisco and attends pharmacy and therapeutic commits for laguna honda and General Health and San Francisco health plan as well, with the goal of providing expertise and evidencebased decisionmaking and formulary alignment and also help with our costsavings measures. Pharmacy is a highvolume, highrisk operation. As you can see a very highvolume, if you looking at almost 4 million doses dispensed during fiscal year 1415. It requires as close as with can get to perfection in order to provide safety as far as operations, Technical Expertise and training of our staff. One thing which we have done in this last year to improve safety in our operations is an alignment with the vendor called ohmney cell for technology across the dph. So we have aligned and have an exclusive agreement withomni cell to provide alignment from operational, clinical, efficiency perspectives, et cetera. Some Program Highlights for 2015 are developing people, it, and then lean work. From a Workforce Development standpoint we have two new pharmacy residency programs which were accredited last year. One is a secondyear specialty psych residency, that we do with ucsf and residents go to ucsf and go to behavioral Health Services and also to sfgh, where they get an outstanding education. And at sfgm we have a new firstyear residency pharmacy program, which receives an astounding 6year accreditation, which is a testament to the great work of this new program. We had a couple of major it implementations this last year. One was in jailhouse services. And the other was in eclinical work implementation at laguna honda hospital and the pharmacy director is also the cmio at laguna honda. This year were working on contracting for outpatient Pharmacy Software with a vendor called qs1 and would like to implement this software at behavioral Health Services and pharmacies the software already existing at laguna honda and would allow the three sites to have Similar Software and potentially allow us to share procedures, operations and hopefully staff at some point. San francisco General Hospital outpatient pharmacy has done some amazing work with lean. Its reduced its wait times from over 2 hours to what is consistently less than 30 minutes right now. They have done this through the use of these sort of lean workshops, which are weeklong workshops where they have actually worked on specific things to improve areas of the pharmacy operations. In these workshops we included staff from laguna honda and ambulatory care and Behavioral Services to get fresh perspective from the pharmacy perspective, but also so that staff could go back to their respective sites and spread the word about it. So for example, with laguna honda after they came to a week longest, they brought the huddle process back to the pharmacy and are doing daily huddles in the laguna honda pharmacy. The pharmacy director there is also worked on the a3 project plans with two she is working on as part of her work with lean. There are ether areas of there are other areas that were involved with and taking expertise at one site and sharing it with other sites. For example, when laguna honda wanted to put together a new anticoagulate clinic, they looked at the standardized procedures that the pharmacy used and pharmacists used there and the operations and took a look at it and they saw what would work and what might fit at laguna honda when they developed that program . Behavioral health has been involved with the dope project for many years and we use the expertise of the pharmacy staff and provider staff there, when we wanted to expand the other areas. Operationally, i have hit on most of those already. Right now the pharmacy for 2016 is going to be working with Human Resources on the performance appraisal project. Where Human Resources is looking at the developing an electronic performance appraisal system. Because pharmacy is also integrated it makes sense to use pharmacy as one of the pilot sites for that. And so well be looking at the different classifications in pharmacy and seeing how that works and how we can learn from it . Challenges so as many of you may have seen, like from the wall street journal at the beginning of this year, here is a quote from the wall street journal, u. S. Prescription drug spending rose 12. 2 in 2014, which astounding. We have been able to keep our inflation rates significantly less than that. But this is what wore seeing throughout the country. A week later the Washington Post noted greater than 10 Price Inflation during 2015. Overall its projections that inflation for pharmaceuticals will increase 2030 over the next five years. Last year there were 45 new drug entities approved by the fda and many of these entities are what many consider to be breakthrough drugs, which offer astounding prospects for our patients. These are drugs which we want to use and make available, but they come at a significant cost. Luckily we have an increased number of reimbursed patients in our system. In fact, all of our almost all of our areas do have patients with significant amount of re, but reimbursement. As the Affordable Care act has come in, it has gone up dramatically and its a wonderful thing for us and our ability to provide these drugs. Well continue to use guidelines and formulary guidelines for these best processes, but we want to use these new drugs and they will come at a pricetag. Other challenge that well face is the 3 43b program this. A federal drug program, which offers deeplydown discounted drug s to qualified entity. At dph we have two such covered entities and we probably save 24 Million Dollars every year through the us use of the program. The definition of eligible patient, is much more restrictive than we currently have. If this goes into effect, well definitely have increased costs and the complexity of managing the program will increase as well. The dph and the Community Clinic consortium are very interested and we actually did submit comments to hrsa during the Comment Period and were hoping that they will take our views into account before they put together their final guidance. Regardless, were ready to meet whatever challenges come forward. We have a really strong group, which is helping move our initiatives forward and develop the best care that we can possibly for our patients. This is the Leadership Team that we have right now in place. Happy to answer any questions that you have. Thank you very much. It seems that if 12 increase in 2014 and 10 , i dont know how you are going to hold it down 2030 over five years. Luckily, actually our inflationary increases have not been that. We have been more in the 4 range here. You can see that Patient Assistance Program number 7 million of costs that we averted through the programs. Some of the programs are really restricting their use, especially hepatitis c drugs. So were probably not going to be able to make use of the programs like we have in in past. Why is why i think that 20 inflation rate over five years is probably what were going to see. Were currently trying to project out a 5 annual inflation rate fighter for the next several years. Commissioner taylormcghee. Thank you for your report, which was very highlevel. I would like to dig in a little bit and ask you a couple of questions about things that i care about. Womens reproductive health, whether its emergency contraception or any other kind of familyplanning measure. How does that fit into your patient care goals . Where is that in the scheme of things . Also Medication Management, which i think is really important. You mentioned pain management, but that is different from Medication Management, as a pharmacist you know that. So give me just a little bit where that fits into the new scheme of things . Womens health, we have a clinical pharmacist, which we hired in the last three years to look at Womens Health. She is based at San FranciscoGeneral Hospital and she works with the Womens Health group there. She also works in the inpatient and clinic environment for them as well. She has been active with that group not only locally, but also with regarding some, i guess, items of interest, nationally. And putting her perspective there. As far as mtm goes this is an area that pharmacists have a lot to offer regarding Medication Management. There was a meeting this last month working with San Francisco health plan to determine how we might work with them, in partnership, to provide more Medication Management therapy services. Right now the health plan actually has a plan in place where outside pharmacies can provide medication therapy management to outpatients and were interested seeing if we can use our pharmacists to do that . Because especially our ambulatory care pharmacists know these patients just, as well or better than the Community Pharmacists do and we think its a really Good Opportunity to align and provide care, as well as to get some reimbursement back for the pharmacists. Right now were having a conversation with them about that. Thank you. Commissioner pating. Thank you so much. Im so glad were having integrated conversations regarding our pharmacy. Were one big system and we should try to use as much purchasing power as we can and coordinating that way is the way to do it. The biggest thing that has been bothering me, though, when i have gone through my tours that the jail doesnt and laguna honda dont get 343b pricing. Because i think its the medicare enrollment rate is the driving factor. Is there any other ways that we can get specialty pricing . What about, is there any multicounty collaboratives . What if we linked up with santa clara, los angeles, alameda and the biggest darn purchaser in the country . Could that be another way, not to get around 343b, but to work with purchasers to get really good rateds. We do get pricing at laguna and Behavioral Health. Obviously its nothing like you can get with the 340b or valevel of pricing. There are some collaboratives that the jails have, that we could potentially look at, and i have sat on a number of calls with the state regarding that. Its sticky. Its complicated, and im not sure what more we would be able to get in addition to that . I have looked at the possibility of 340b in those sites. Where hrsa not coming up with the new definition of patient, you probably would have a Budget Initiative for something to do with jail this year. But clearly the draft legislation that hrsa has put out with 340b will clearly not allow that to happen. So if the definition does change, there is something that we might be able to do with the jails as far as from a clinic perspective with 340b, which i think would be a thing to look at. Im really glad that we have smart people like you coordinating our efforts and looking at it. Regarding smartness, the hep c treatment not to name the treatment by name is now medical funded. What would be the cost to us if we bought as much and gave away at medical cost as possible to treat our population . Are there hidden pharmacy costs we would incur . Or would it be strictly a passthrough to get as , as much as this hep c drug to our patients as possible . The 7 million in savings, 5 million is probably hepatitis c drugs. When those drugs came out, healthy San Francisco patients are eligible. Our healthy worker patients, we actually found a way to get that for our healthy worker patients as well. Then initially those medical was denying those until recently in july when they changed their rules and we would actually, if medical denied it would sent to the Patient Assistance Program to get funded that way. Now they are being funded through medical. We could pay for those drugs through our farmcy, pharmacy, if we wanted. We wouldnt make much money on it. So those patients do get them in the community. Does that answer your question . Yes, it does. Sounds like we have a net savings the way were currently structuring. Right now its a lot of gillad has changed the rules for that program. I didnt speak them out earlier, but they are the ones that have completely changed the eligibility rules for their program and basically they are saying now, we go by the persons insurance. If they have insurance, we go by it and if the insurance says no, we say no. Which is different from a yearago. So they have really clamped down on that. The other manufacturers have done that less so, but its once a day and covers most of the genotypes and its the preferred option. Can you tell us the cost without a benefit . A beneficiary or payer . The cost to a patient would be 70,000 80,000 for a course. Our cost is significantly less than that, if we had to purchase it, but its still maybe half that. If we had to buy that for a patient. So were fortunate that healthy San Francisco still are eligible, all of those patients are eligible. Healthy workers are not currently and were probably going to street to pay have to pay for them at some point. With regards to the new computer, well be able to hook up to epic; right . That is such a dream of ours. I mean our world, especially in hospitals we sit between the providers and sometimes between the order and between the nurses administering the medication. Seamless system can go back and forth, being able to do medrack between laguna and between sf gh and others is a dream of us. Its truly a safety initiative. And efficiency. I mean, there is a huge amount of safety and efficiency that the pharmacy will begin by having an enterprisewide Electronic Health record and i cant tell you how happy i am with the epic that is reassuring. Thank you very much. Whatever we have as an integrated system. Uc is epic and sharing resident on the pharmacy side and students, as well as medical trainees. I think most people we actually looked at cerner and epic as part of bill kims process. Epic is incredible. That is another good reason to try to negotiate with the better pharmacy interface. Any further questions . Excellent program. Thank you very much. Again, a wonderful demonstration of where we have moved forward in terms of integrating across our system. Thank you. Thank you. Can we go to the next item, please. Yes, commissioners, item 8 is a resolution authorizing the dph to recommend to the board of supervisors to accept and expand retroactively a gift of 100,000 to the laguna honda. This a very good action item. Good afternoon, president chow and members of the Health Commission and director garcia. We are so grateful to miss molly fleischner, a resident of San Francisco, who has generously provided laguna honda a donation of 100,000, specifically [ inaudible ] who are otherwise unable to obtain them. I am here to request your approval to forward a resolution authorizing the department to recommend to the board of supervisors to accept and expend retroactively the gift of 100,000 from ms. Molly fleischner to the laguna honda fund. I can answer any questions that you may have . Thank you. Thank you. Commissioners . So moved. Could you tell us who miss molly fleischner is in terms of her relation with laguna . And what created this very nice gift . Ms. Molly fleischner lives in zip code district and she is a friend of one of our volunteer chaplains. I meet with the volunteer chaplains on an annual basis and we have a conversation. And in october of this year, when i met with one of the volunteer chaplains, she had informed me about ms. Molly fleischners intent to provide those donations specifically for residents who need assistive technology. Wonderful. Any further questions . There was a motion at had this point to recommend to the board of supervisors to accept this. Very proud to second the request. Okay. Any further questions . If not, then let us vote on the motion all those in favor, say aye . Aye. All those opposed in motion passes unanimously and we thank you and we thank ms. Fleischner. Thank you, commissioners. Item 9 is other business . Any further business, commissioners . We might point out the planning session, which were hoping will also be instructive in terms of the lean process is scheduled for what date . April 19th, i believe or april i dont have the calendar in front of me, but its midapril. Thank you. Great. Okay. Any further questions . Other business that commission wishes to bring up . If not, shall we go on to the next item, please. Item no. 11 is committee im sorry, no. 10 is joint Conference Committee reports and commissioner pating is going to report back from the january 12th laguna honda j cc meeting. We heard three reports. One was on the laguna honda hospital Palliative Care program and again, another model program. Both state and in the country. 250 patients go to laguna honda, but i think what was most amazing is compassion and consideration that the staff gives to making end of life care both comfortable and very spiritual experience. So we were hoping that the commission might at one point get to participate in recognizing on an annual basis some of the wonderful work by recognizing through a memorial of people that passed away at laguna honda and perhaps going agendize it at a future laguna honda meet we also talked in the context of that and give you a heads up, its probably an item that will come up before the San Francisco general j cc, which is the issue of physicianassisted dying passed into law and governor signed it and you think laguna honda and San Francisco general and Health Network staff will probably need to establish a policy around it, so there is consistency. That came up at meeting of the lastly, there was a discussion around laguna honda, moving on to a true north scorecard and we were very excited able to to hear the Strategic Plan and how plan will be implemented and reported out to us on a regular basis. And then in closed session, we approved a hospitalwide policies and procedures as discussed in the administrators report. That is what we did. Thank you thank you. This commission of course is interested in Palliative Care programs. So as you develop something that could be brought forth to the commission, i think we would very much appreciate the update on the assisted dying dont we also need to wait for to be chaptered in law . Which i understand is still pending, but according to the Palliative Care force is still pending. Thank you for the correction. Its pending a special session of the state legislature and i guess it doesnt get chaptered until it comes out of special session. So i just wanted to give a heads up, when it does, there will probably be a need for further systemwide discussion on the issue. Very good. Any further questions to commissioner pating . If not, we can move on to the next item, please. Item 11 is community agendasetting. I think i guess i preempted that already in terms of the planning session. We also have a calendar before us, if anyone has any items that they would question or would like to add to our calendar . If you dont have it right now, if you would bring that to mr. Moras tension. Next item then. Closed session will be deferred because the documents were not ready. Its a simple administrative item and to move on to to consideration of adjournment. Fine. Motion of adjournment is in order. So moved. Second. All in favor, please say aye . Aye. All opposed . This meeting is now adjourned. [ gavel ] good morning, everyone. Thank you very much for being here. San francisco is thrilled to be hosting super bowl 50. When we found out we were hosting super bowl 50 we were planning right away. Weve been planning last spring with many exercises and pulling together our regional partners and local and federal partners to make sure that super bowl 50 is a safe, fun, experience for everyone who comes here. Its the golden anniversary of the super bowl. Thats something to really celebrate and we are thrilled that San Francisco was chosen for this honor to be the super bowl 50 host. Today, we have what we are calling a super bowl scrimmage. We have the second of three exercises that test our assumptions, refined our plans and actively engage our players in planning and response. Each one of these we learn new things. We alter our plans and define them an deconflict them and as we move forward we are speaking with one voice and we know what other agencies are doing and what assumptions are in place. Our goal is to work through all of these challenges together. So, again, super bowl 50 is a wonderful fun family event thats going to be 9 days long here in San Francisco. We want people all over the region, all over the world to come and celebrate with us. We think that unfortunately our own team will not be part of this. But, other than that, its like it is the perfect event for San Francisco and the bay area. We want to encourage efrj everyone in San Francisco and sf to be alerted. It will be an important way to get messaged about with such information as what streets to avoid or what areas to avoid. So please encourage your residents neighbors to sign up for alert sf. Im going to introduce my good friend. Police chief suhr who is going to come up. There you are, chief. Hes going to give us a few words of wisdom. Thank you, ann. I will preface my comments as a lifetime 9er faithful, im not ruling out that we are in the game. Dont give up. Anyway. We are so excited to be hosting the 50th anniversary of the super bowl. Again, the planning has started in ernest pretty much as soon as we won the bid for our chance to show case San Francisco and as police chief of what i believe is the finest Police Department in the country, we want it to be as safe as it can be. Weve been to the new york fan fest where the super bowl played in new jersey, weve been down to arizona, where the super bowl was played in glendale and went to the phoenix Police Department to see what they do and it got us that much more excited to be able to host this event over a 9day period event in San Francisco. One thing San Francisco is good at is planning. Its what we do. No matter what eventuality that happens, our Fire Department and with the leadership with the Mayors Office, we plan as if that event happens here. Pretty much for every eventuality all the way up to and including typhoons and or anyway, tidal waves. So, or tsunamis, which we hope never happens. That said, well be planning and it will be a great event where we plan and get to know each other. Everybody has each others cell phones and we work with our state and federal partners on what may come and i cant say enough how much preparation is going into this effort to make sure that it is safest. I know with events going on overseas is leaving people right now anxious. Again, its just one more variable that we are training to. We are in regular contact with the fbi. Again, there are no known threats to the united states, no known threats to San Francisco and certainly no known threats to the super bowl. That communication will remain open regular and we will absolutely make sure that every precaution is taken to make sure the whole world can come to the super bowl in late january and february and have hopefully what is going to be the best super bowl and best fan fest ever here or nfl experience. I would just say as police chief here in San Francisco, you are all invited. Thank you, chief. Now i would like to introduce our very own fire chief chief hayes white. Good morning, everyone. Like the two previous speakers, San Francisco is very enthusiastic about hosting super bowl 50. Although we wont be in shoulder pads and cleats. The people behind me gathered around the city are like a team. We are the team preparing, planning and communicating about whats going to happen end of january, beginning of february. We are very well prepared and thats what you see today with the men and women of San Francisco county and state and regional partners. What i want to advocate to those visiting San Francisco is we will do our utmost to keep everyone safe. We operate at a high level in San Francisco. We know there will be additional challenges but we are up to the challenges and as a team we are practicing and per perfecting and we are going to assure everyone that we are going to respond to emergencies outside of the super bowl as well as those coming to the super bowl. Chief suhr wanted me to pass along what he always talked about and not just from Law Enforcement but Fire Department perspective. If you see something, make sure you say something. Its important to utilize 911. If its not an emergency you can use 311. If you have some ideas related to preparedness and transit, make a good plan and utilize all the citys resources many we want you to understand that from the San FranciscoFire Department that we have 15 more aramedics that will be available. We have private providers as well. We anticipate we will have a high call volume during the period of time, but we are prepared and ready and look forward to hosting everyone here in San Francisco. Thank you. Thank you, chief. Im going to call chief suhr back up real quickly. So my partner at the Fire Department shouldnt have to say what chief suhr said with chief suhr standing here. Anyway, with all of our devices we are never going to be as safe as we can be with the millions of people in San Francisco looking out for one another. Whoever comes to the nfl experience during those 9 days. Especially right now with everybody anxious in San Francisco and around the country. Please, if you see something, anything remotely out of the ordinary. Please call. 911 is on alert to expedite calls. That will be the case in the nfl experience as with other major events with our three world series championships and runs with super bowls in the past and other major events in San Francisco. We need to remain vigilant as a city as a whole when it comes to taking care of one another and looking after one another. Thats when we are going to be safest and you will get the most Rapid Response you can possibly get to checkout any possible potential concern. Er on the side of the caution, if its nothing, no problem. You would be remiss what i always call a predictable surprise where you saw something and didnt say anything and something went on. Just call us. Thank you, chief. Now i would like to introduce our director of sf mta, ed reiskin. Thank you, good morning, everyone. I would like to thank ann and the team for her leadership and what the team referenced. To put on a big event like this does take a lot of coordination and planning and is really preparing us for anything that might happen and that planning is essential to making for a great event. It will be a great event as everybody else has said. I think this is a great opportunity for San Francisco whether you like football or not, whether you are planning to participate in these activities or not. The super bowl being hosted here is going to bring a lot of people, a lot of excitement and a lot of goodwill to our city which is a good thing. From a transportation point of view, our task is really straight forward. We want to make sure that people can safely and readily access the event and from and to the event and everybody else in San Francisco can go where they need to go whether its work or school or just trying to make their way across town. We have been planning with the rest of the city planning but also with the rest of the regional transportation agencies and particularly Law Enforcement and homeland security, particularly the Transportation Security Administration to make sure we can have a safe and secure event and from secure transit agencies. We want to encourage everybody to take transit because of the transportation we have developed is very much reliant on people taking transit. But for people taking transit, we want people to report anything that looks suspicious or worry some. Like the chief said, call 911 and let them do their job. To support Emergency Services in particular, part of our effort is mapping out the security routes, the Emergency Vehicle access routes to and from all of the various events in the area to make sure that without being impeded, they can do their work. And then in terms of the Transportation Service itself, weve been working with all the providers and particularly with muni which is going to do a lot of the heavily lifting for this event to make sure that where we can work around and with the street closures to make sure that everybody who wants to take transit from and to the events can and everybody else who uses transit on a regular bases can get to where they need to be going. Weve been able to figure out routes to the buses and figure out where the taxi stands will be and the Emergency Vehicle access will be. This is something we do for many large special events. We did it for americas cup and for other large parades and other large celebrations. We are very confident in our ability to ensure people get to where they want to go whether they are participating or not safely and efficiently. We will be encouraging folks to use transit and just to address an issue thats been out there. There has been a lot of talk about the impact that sites down at the foot of embarcadero on muni might have overhead wires. Weve been working hand in hand with the community over many months as they are refining their plans. The issue with the wires if you get close to the wires, thats not a safe situation and we need to move