JamesLHollyMD.com

	James L. Holly, M.D.

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In The News - American Medical Informatics Asssociation December 2013 Pi2 Award

Pi2 Award Nomination Package

Project Name
The Automated Team

Organization Name and Location
Southeast Texas Medical Associates, LLP Beaumont, Texas

Team Leader Name and Contact Information
James L. Holly, MD
2929 Calder Suite 205
Beaumont, Texas 77702

Team Member Names
Richmond Holly, Chief Information Officer
Jonathan Owens, Clinical Systems Engineer
Margaret Ross, Director of Operations
Jayne Bryant, Nurse Quality Officer
Theresa Bailey, Nurse Quality Officer
Pat Crawford, Director of Care Coordination

Project Goal
How many tasks can a primary care provider do at each patient visit? That question was asked at a conference in Boston in May, 2012. There were many answers, but the question was answered by asking three other questions:

How important is the task?
How much time does it take?
How much energy does it take?

If you were to create a formulae to represent this process, there would be a direct correlation between how many tasks a provider can or will do and how important the tasks are; the more important the tasks, the more tasks a provider will do. There would be an inverse relationship between how much time it takes and how many tasks will be done; the more time it takes, the fewer tasks will be done.

There would also be an inverse relationship between how much energy it takes and how many tasks will be done; the more energy it takes, the fewer tasks will be done. The key to getting more done is to determine what is important and only to do that, and then to make the completion of the important tasks require less energy and less time.

How can we change the future?

Make it easier to do it right than not do it at all! Imitate Henry Ford who automated the manufacturing of automobiles with assembly lines and in so doing made it possible for those who made cars to afford to drive them. There are many aspects of patient care which can be automated. Classically, SETMA has used clinical decision support as reminders to providers, but now we are realizing that many of the tasks which were the object of CDS, actually could and should be automated, requiring no input from the provider. For instance, the value of the flu immunization is not enhanced by it being ordered by a healthcare provider, or by it being given by a registered nurse. And, the process of a flu immunization can be automated.

Automation will decrease the time a provider takes away from a patient-centric conversation and it will increase the provider’s performance on important screening test, preventive treatments and fulfillment of important quality metrics. It is expected that The Automated Team project will decrease at least 30% of primary care provider’s work load.

Description

In 1993, John Patrick set IBM on another course and changed the company's future. Reading his story made SETMA wonder, “Is it possible for SETMA to set medicine on another course and to change the future?” John did not want people to work “collaterally,” side by side, maybe going in the same direction, maybe even having the same goal, but working independently and at best in a cooperative manner; he wanted people to work “collaboratively,” synergistically, leveraging the generative power of a team in creating a new future which they partially envision but which even they could not control.

SETMA asked, “What can we do today in healthcare which would mirror the changes IBM experienced? How can we change ‘collaterallists’ into ‘collaborativists’? How can we use the power of electronics, analytics, and informatic principles to energize radical change to create a new future in healthcare?’”

As we learn more about how to improve our health and as we are able to change the future of our health more, excellence in healthcare increasingly is dependent upon two things: a team approach and the automation of standardized tasks, which, while they are critical to excellent care, can be completed without requiring the time and attention of team members. This gives the team more time to interact with one another personally. This standardization and automation of care brings us one step closer to the ultimate promise of electronic patient management which is the appropriate goal of electronic patient records. The Automated Team is the logical extension of clinical decision support.

The majority of healthcare is delivered and received in the ambulatory setting in a clinician’s office. While the healthcare team is much boarder, in the ambulatory setting, the principle members of the team are the patient, the nursing staff and the healthcare provider. Ultimately, while the standardization and automation of this team’s functions will spread across all areas of care, Southeast Texas Medical Associates’ efforts begin with diabetes. Each member of the team - patient, nurse, and provider -- contribute to the excellence of ambulatory care for diabetes.

When a patient who has diabetes makes an appointment, based on evidenced-based medicine and national standards of care, the electronic record will immediately search the patient’s entire medical record to determine what tests, procedures, consultations or interventions are required and which have not been performed. Each of these interventions will be directed at the prevention of the complications of diabetes and/or at the improvement of the care of the patient with diabetes. Because diabetes is a progressive disease, excellence of care at one point in time may not reflect excellence of care at another time, thus the reason why the “automated team” needs an updated, current and complete plan of care and treatment plan at each visit.

When the patient presents for their appointment, three documents will have been prepared:

For the nurse, a document will have been prepared which lets the nurse know what elements of his/her contribution to the team’s effort are not up to date and need to be addressed, such as The LESS Initiative, the 10-gram monofilament sensory examination, immunizations, medication reconciliation, etc.

For the patient, a patient activation and engagement document will have been prepared which tells the patient what tests, procedures or referrals have been scheduled. An explanation will be provided to the patient as to why he/she is being asked to have these tests, procedures, or appointments. As stated above, all interventions will be directed toward the improvement of the patient’s care and the avoidance of the complications of diabetes. With this document, the patient will know what his/her responsibility is to support the efforts of the team.

For the provider, a document will have been prepared which explains the information which has been given to the nurse and the patient. The provider will be alerted to whether or not the patient has been treated to goal for diabetes and if they are not, the provider will be encouraged to change medication, life-styles, education, etc., in order to achieve control.

The Team’s Activation - True Patient-Centered Care

Each team member will have access to the documents given to other members of the team. Each team member will know what is expected of the team and each team member will know what the goals are for the entire team. Because the team will be spending less time on the tasks of ordering and scheduling tests, procedures and referrals, there will be more time for the building of relationships and for the engagement and activation of each member of the team. The Automated Team has been deployed for diabetes care and has been functioning for six months. It is performing excellently and is accomplishing all of the goals for which it was designed.

EMR Deployment of the Automated Team Function for Diabetes

Over time, SETMA will build the Automated Team functions for all chronic diseases, such as hypertension, congestive heart failure, chronic renal disease, cardiometabolic risk syndrome, Dyslipidemia, chronic stable angina, etc. The Automated Team functions will also be built for the fulfillment of HEDIS measures, ACO quality metrics, Medicare Advantage STARS quality metrics, and for the over 300 quality metrics SETMA currently tracks, audits, analyzes and publicly reports provider performance by provider name. SETMA hopes to have all of the Automated Team functions for all of the chronic conditions we treat built over the next twelve months.

The Automated Team Process

When a patient makes an appointment, the computer automatically and independently:

Searches the patient’s record for all chronic conditions for which the patient is being treated.
Creates orders for procedures and tests and referrals for appointments with other providers
Creates a patient engagement and activation document, a nurse’s responsibility document and recommendations to healthcare document

This will leave more time for the provider to listen to the patient’s healthcare concerns and desires, to modify the patient’s plan of care and treatment plan to improve outcomes and to make certain that the grasps the “baton” through which the patent will accept responsibility for their care. We believe that when complete, the Automated Team functions will free up 25-35% of the healthcare providers’ time, allowing all quality issues to be completed successfully and allowing the healthcare provider to spend more time with the patient.

There is one major question which we hope to answer over the next three years. SETMA providers currently meet the standards for NCQA Diabetes Recognition, NCQA Tier III and AAHC Patient-Centered Medical Home standards, and NCQA Cardiac/Stroke Recognition. We expect the Automated Team function to improve our already excellent performance with less effort and less time required by the provider and as new providers join SETMA in the coming months and years, they will adapt to our system well. When adopted by clinics which are not performing well, the value of the Automated Team will be seen.

The complete description of The Automated Team and a Tutorial for its use can be found on SETMA’s website at the following link: Tutorial for the EMR Automated Team Function - How can we change the future?

Nomination Letter

The Lead Candidate’s Bio

James L. Holly, MD, is Founder and Chief Executive Officer of Southeast Texas Medical Associates (SETMA, www.jameslhollymd.com). He is a graduate of the University of Texas Medical School in San Antonio, where he is an Adjunct Professor of Family and Community Medicine. He is also an Associate Clinical Professor in the Department of Internal Medicine at Texas A&M College of Medicine.

In 1998, Dr. Holly led SETMA to adopt electronic medical records. SETMA has become a leader in healthcare informatics winning many awards including the HIMSS Davies award and Stories of Success, and the eHI Innovator of the Year in 2012. Dr. Holly writes and lectures extensively on health policy, informatics and healthcare transformation. SETMA is an NCQA Tier III Patient-Centered Medical Home and is accredited by AAAHC as a medical home. In December, 2013, SETMA will be accredited by URAC as a Medical Home and in February 2014, the Joint Commission will survey SETMA for Medical Home accreditation, making SETMA the only practice in America with Medical Home recognition by all four agencies. In 2010, AHRQ published SETMA’s LESS Initiative on their Innovation Exchange. SETMA is a Joslin Diabetes Center Affiliate. HIMSS published SETMA’s history on their Stories of Success website. Dr. Holly was named the HIMSS’ Physician IT Leadership Award recipient for 2012.

Starting in 2009, SETMA has publicly reported by provider name on over 300 quality metrics at Public Reporting of Provider Performance on Quality Measures. SETMA is a participant in The Guidelines Advantage Program and Dr. Holly serves on The Guidelines Advantage Steering Committee. For the past fifteen years, Dr. Holly has written a weekly, 2000-word, healthcare column. All columns are posted on SETMA’s website under Your Life Your Health. Dr. Holly serves on the Board of Directors of a federally qualified ACO. SETMA is a member of the National Quality Forum.

A current copy of Dr. Holly’s full CV can be found at the following link:
James Holly M.D. Curriculum Vitae

Nominator
Syed Imtiaz Anwar, MD
Fellow American Board of Internal Medicine
Partner and Chief Medical Officer, SETMA

Nomination Supporters

Francisco G. Cigarroa, MD, PhD Office of the Chancellor
The University of Texas System
601 Colorado Street, 4th Floor
Austin, Texas 78701

William L. Henrich, MD, MACP President and Professor of Medicine
The UT Health Science Center at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229

Paul Grundy MD, MPH, FACOEM, FACPM
Director, Healthcare Transformation, IBM
IBM's Global Director of Healthcare Transformation
President, Patient-Centered Primary Care Collaborative

Francisco GonzÃ¡lez-Scarano, MD Dean, School of Medicine
Vice President for Medical Affairs
Professor of Neurology
John P. Howe, III, MD, Distinguished Chair in Health Policy
The University of Texas Health Science Center at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229

K. Ashok Kumar MD., FRCS., FAAFP Distinguished Teaching Professor
Vice Chair for Medical Student Education Family Medicine Clerkship
Director Department of Family and Community Medicine University of Texas Health Science Center at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229

Related Letters

	An Appeal to CMS and ONC for a Temporary Exemption to Meaningful Use 2

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