we have more diverse services than any other health care system i've seen which means it's very difficult to buy a single platform that will meet all our needs. in the future it could be that a single platform could do everything we need it to do. maybe they can't. but whatever it is, we're going to put in the capabilities that will meet our needs. having done all that, we will be green. the question is how long will it take to get here. in the previous slide everything was too much red. okay, here are the dates. the next two years we're going to work on building a strong infrastructure foundation. we are going to build effective it. that means our team, not only hiring more people, which the department of health has been very great in providing support and a lieuing allowing us to hire more staff, but more importantly training them so our employees are better, more

effective. but also building a clinical support team that can support our clinicians and nurses and ancillary team to use the tools we invest in, the tools we buy. having that we will be able to perform a full due diligence and planning for the next stage which is the next generation health system functions. we will not do what many organizations have tried to do and fail. many of you may know many organizations in their urgency will go ahead and sign up for an hr system, purchase it, attempt to build it and fail. there's a very common mistake as we look at these people who failed. they did not have a blueprint of what they wanted. they had a high level requirement of what they wanted or what they thought they'd like to see, but no blueprint. it's like building a house without a blueprint. you draw your blueprint as you

build your house. the probability of that succeeding or having a house that you like is probably very low compared to a full blueprint that you agree on. we need this team -- we need an effective, strong, infrastructure foundation so we could free up our team in the clinical support team we're building to no longer fire fight, but to do due diligence in planning this blueprint. once wif we have a clear blueprint across dph we will know exactly what system to buy. that will be the next generation of electronic health system. once we put that in place we'll be able to take all the other technologies we're investing in, the technologies we have, and be able to integrate that if the hr system to provide an integrated d health hr system

across integrated care. how is that different than an hr system. the hr system is place where you put records for data. an integrated health system would now create a synergy between the two technologies. we want to be able to provide integrated health across multiple forms of technologies, not only tele health, voice communication, texting and so on. so for those who are more graphically inclined i actually created a picture of what i went over in a house format. you have the foundation, infrastructure, and more importantly the support pillars, the effective it, and the left which is operational and project management capabilities and on the right the clinical training and

optimization functions under the clinical. once we have this , we can move away from fire fighting and start to build. looking from bottom to top, we can look at our work flow. we need to know what we want. not in high level, but in detail, specifics. we need to apply lean and it delivery service models that are well accepted in the industry. by then we could add a value to our processes. and then when we complete that we'll have a right solution for our blueprint. once we have that, we could proceed in putting in unified electronic health record system. after that's done we could create inner operable blt across all systems.

the last slide i'd like to really point out, what do we really need to succeed, what do we need to do differently than what we've done. if you remember one, it's invest in foundation and i'd like to thank director barbara garcia and the directive team an commissioners for helping us invest in our people by

providing train inging, helping us bring better infrastructure. more importantly as an it organization and whole organization, we need to align all efforts with business goems. we need to be doing due diligence and planning and reduce power ties. we need to be disciplined.

the collaboration, support, recall of that really has to be infused into technology into the work flow in technology otherwise the technology we buy and implement will be taking what we have today and just turning out a new version of it. we need to move beyond where we are in order to succeed in the future. that's all i have today. any questions? >> commissioners, was there any public comments before we drn -- >> i have not received any requests. >> thank you for this and thank you for the well thought out way forward with the building blocks. i have -- and some timeframe that seems -- i mean, everybody would like to have this fixed immediately but i think you've made it clear this is going to take investment in people and

processes in this integrated system at the end of the day and you point out that there are eel be analytics built into big data. are you anticipating that that will include decision making outcomes that the end user can use? >> yes. >> as well as the research endeavor? >> in my mind we need to utilize all the data we have so that can benefit not only the city, but the world. >> i think that's particularly important to talk about when you talk about team work being at a much higher level than the five levels on the unit that the five units on the unit might add to big data that would help with decision making that could stabilize down the way. >> i think it was a very excellent report that you shared with us.

i was thinking here are the problems now with the options and i think you really hit it in reference to we're not looking at specific programs to make new pathways that suddenly come up and i can name a host of them that many of them have seen over the last 15 year years. you come back and forth and say well, this is going to work it

seems rational when i think that's about the time we'll be rotating off the commission after many years and finally it happens, you know, i'm looking forward to that day but it was a really excellent presentation and i think it gives us and our colleagues, both in the department of public health a real unique opportunity to think about the timeframe in essence and also the pathways you shared with them and i know you are part of the over all team that our director has looked at. when you're talking about coordination of systems from a to b. you have articulated it well. thank you very much.

>> one thing i'd like to reemphasize. we have a very good start. 2014 to 2015 i believe we have a very good running start. we have a lot of support from the organization and i think we will meet our goals. one of the things that will dictate if we have full integration in 2018 surely is a question of funding. we have a lot of things that used to be purchased and integrated in order to provide all the functionality that is coming down the pipe. now, having said that, there's quite a bit we could do with what we get. i think it's really being disciplined and focusing on the things we need and not focusing on the shiny things that other people want us to buy.

>> thank you. >> commissioner. >> thank you mr. kim for that presentation. so what i'm hearing a lot here are really infrastructures and also, you know, like, an integrated systems to support our staff and our clinicians to do the job better. so from the patient's perspective, maybe i'm a little bit spoiled because i relate to my own experience with, you know, my own electronic medical records that i'm actually able to access that any time i want. i think that there are benefits to that, you know. i would be able to look at the lists of medications that i've been prescribed before and also all the current lab work that i have recently done and that helps me to really improve my health literacy and be an

active advocate for myself. in terms of how -- a vision for the it system how would that play out for our patients and would you call that shinny? >> i would -- let me show you a picture of my vision. this is using technology that exists today, but combining them to create additional value so imagine if you will you're a patient and just got admitted to an ed and in the ed soon as you check in the system knows what your probability of readmission is the next 30 days. we have that capability today in the world using data such as how often you are visiting the ed, what your health status is and so on.

imagine that information not going directly to your doctor or nurse, but to your case coordinator or somebody that's going to follow up with you when you go home because really what you need is better care and reminder at home. the nursing department, time to staff the nurses, no longer rely on paper showing what patient is getting what service. relying on the emr or hr system that is realtime that calculates the patient's acuity and recommends based on the input you have and the regulations you live by, what your patient's staff and nursing staffing ratio needs to be. that exists today.

all of this technology exists today. it is the technology that only happens when you have the full integrated system. that is the vision that i foresee, commissioners. >> that means that that's something we want to look forward to? >> yes. patient care should extend out to -- outside the walls of the hospital. >> this may be the bridge to the next subject.

within these -- and i think this is color coded too, right? >> yes. it is. >> so we got to get color presentations because these don't quite come out in black and white, but we're going to go from red to green, but we're talking about in the budget to be presented this afternoon as the next item, are the items that you need funded within this to do the 014 through 2015 structure? >> yes commissioner, i believe that the budget i have discussed with the cfo and the executives does support everything we need to do for 2014 and through '15. now, could we use more? absolutely. but i believe we have enough to have a good running start. >> no. that is enough to do what you are putting on paper here and getting us into the effective it clinical and due diligence. we're not going to hear in

december that suddenly you need 50 more people or so? >> no. what will most likely happen is this time next year when we're doing the budget i will have a better picture and will say i won't need as much or will need more. but this depends largely on what i know today. there's quite a bit of work to do. having said that there's a lot of transition and change within the city. for example, we no longer are planning to house all of our servers in our own data center unless the servers is required for emergency situations such as a pack system in the event of a earthquake and where the building's isolated. we don't really need a server hosted there. that means we can save significant amount of money by hosting it within the san francisco's data center which we have a system for. as those things come online or

financial operational cost will change. that's not to say it'll come out of a lump sum saving. more likely it will have to be redistributed in the clinical area. >> and therefore for the items we're going to be looking at really don't speak to 2016 through 2018 yet. >> yes. . >> that's what you clearly put as after having put infrastructure. >> that's right. >> thanks for the questions. there might be some coming up later so if you're able to stay -- >> i will stay and wait for your questions. >> thank you very much for the presentation and we'll look forward to its implementation. shall we call the next item please? >> yes, the next item is the dph budget for the fiscal year

2015 to '16. >> i'm going to go through some of the details and then have the staff from the divisions in the room to answer questions for you. i think in terms of context for this budget we're going into '14, '15 budget year with a projected budget for $1.9

million currently in negotiation, other items that move between now and the mayor's budget submission on june 1 but that's about where we are. i think we're at a moment of brief calm in the eye of the storm here in terms of our finances and that's largely thankful to two things that have given us a brief window to assess and plan for the next coming years. the first is that in last year's budget cycle the mayor's budget included as we discussed here a major investment in the health department to correct our structural salary imbalance. that was on the order of a $50 million recollection which means for the first time in this year we're not grappling to get back to zero before we start planning for our budget. that has created some relief for the department. the second is that in the up

coming budget for '14, '15 and '15, '16, the mayor's office has absorbed the state take bake of back of our realignment dollars, that's the $35 million revenue lost that the state will be recooping in anticipation of health reform. had we been asked to balance around that revenue loss we'd be in a very different place today so i think it's important for us to keep that in context about what the commitment that the city has had to the health department in terms of putting us in a place where we're on, for the moment, stable footing. but what we do need to do is now -- because we we have a moment to breathe is plan for what's ahead and what's really ahead for us, as we all know, is the affordable care act and the fact that our revenues will

come to us in very different ways. we will have to be a provider of choice, we'll be in a more competitive environment and it will be on us to make sure we take the steps that we need to to preserve and protect our revenues and therefore our system of care. so that's the context that we have used to guide this budget. we've spent the last three years, really, going through a number of strategic planning processes in anticipation of the aca, we had the integrated delivery system planning process. we had the h ma planning process over the past year to 18 months, we had the it strategic planning process and process through this commission for our five year financial planning priorities and all of these processes we've tried to

use those to channel what initiatives are going into this budget submission and i think we have done a prudent, but targeted job of trying to channel our efforts through the budget that's if front of you. a couple of quick comments that is fairly significant that is going to change a little bit at your next meeting because we notice that there's one of the initiatives that doesn't have the fd con associated with it, but it is a 1 percent change in our fte positions. we'll get you some numbers on this, but we are recovering. if you look at our fte history, there has been a dip over the last several years as we went through the difficult financial

times and we're recovering some of that, but we're trying to do it in targeted ways so we're making investments in our department infrastructure that will allow us to be a provider of choice and protect our revenues and our system of care. with that, i will turn it over to jen to walk through the presentation. >> afternoon commissioners, i think these first two slides, greg just went over, but this is the context for our budget where we talk about what we don't face an immediate financial crisis, we need to make investments in our system to make sure we are successful if in an era of healthcare reform.

just using the modest revenue growth that we project we are going to invest to make us stronger. without further a do, i'll go into the details of the initiative. first off is baseline revenue growth at san francisco general is projected at approximately 17 million for the next two fiscal years. again, this does not include the 33.8 million of the state realignment reduction that we are also expecting. again, this was included in the mayor's projected deficit so we are not responsible for that so this allows us to put $17 million towards our balancing and towards our target. second we have laguna honda baseline revenue growth. the revenue growth is primarily driven by two major state policy changes. first and foremost is that the governor jerry brown rescinded

a proposed rate cut that he had put into his budget several years ago so while he did not retroactively give us the money back moving forward we can expect increases in revenue. secondly the state also changed how it actually reimbursed us for our cost. previously it had been based on three-year-old cost reports and they waited for the authors of the financials and then paid us accordingly so we are always three years behind in our costs. now they've changed their reimbursement policy so it can actually be based on the most recent closed financial statements despite the fact they're audited and they'd true up those payments down the road. obviously just more recent costs tend to be higher because they reflect the true cost of business, but also more importantly for us, three years ago wrp we were not in our new

facility at that point, which is actually more expensive so this is a one time catch up payment that is ongoing but i don't think we can expect this type of growth in our laguna honda revenues. , you know, without any additional major policy changes. one of my goals as budget director for the next three years is to right size our budget and true it up so it reflects reality of our operations and actuals. so initiative a-3 takes a stab at that where we're just adjusting some of our revenues in primary care and public health. public health historically has been running short of its revenues. it's also been running short of its expenditures. we're hoping to change the expenditure so i want to adjust the revenue part down to get us closer to reality.

on the public health side we have a few areas in the immunization travel clinic and the std clinic which hasn't quite been hitting its revenues. i want to make that adjustment and invest in our public health system. we are back filling some of the from the cdc related to control to make sure we are doing everything we can to prevent the spread of that disease. on the reduction side, they're all actually coming from san francisco general this year so -- and there's two components to it. the first is related to the use affiliation agreement. similar to san francisco general, they are projecting increases and fee for service and rates due to a large number of our patients transferring from low income health program or no insurance to med-cal.

that will allow them to capture payments on their end so they can, for the next two years, cover their projected cola increase. because we had budgeted an increase in the prior two years we can reduce that expenditure for saving. we're going benchmark for san francisco general to improve efficiency and patient flow, then we will actually see an increase in revenues and consequently they will qualify for a million dollar bonus payment in year 15, 16 based on 14, 15 performance. the second part of the savings is related to salary savings as san francisco general. right now it looks quite positive.