JamesLHollyMD.com

	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
EPM Tools Association of Medication and Diagnosis Automated Team Function Behavioral Health Adult Weight Management Tutorial Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care Depression Tutorial Fall Risk Tutorial Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive LESS Initiative Tutorial Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Pain Management Tutorial Reduction of Antipsychotic Medications Toolkit Smoking Cessation Tutorial Stratifying End-of-Life Risk for Hospice Services Tutorial Chronic Conditions Tutorial Chronic Renal Disease Management Tool Tutorial Calculating the Stages of Renal Disease Proteinuria Disease Management Tools Acute Coronary Syndrome Tutorial Adult Weight Management Tutorial Angina Tutorial Cardiometabolic Risk Syndrome Tutorial Chronic Renal Disease Tutorial Congestive Heart Failure Tutorial Diabetes Tutorial Hypertension Tutorial Lipids Tutorial Lipid Quality Audit Tutorial Primary Pulmonary Hypertension Tutorial Framingham Cardiovascular Risk Cardiometabolic Risk Assessment Framingham Heart Study Risk Calculators Tutorial Frederickson Classification of Dyslipidemia LDL Level Lipid Disease Management Risk Assessment General principles about ICD-9 Codes and HCC/RxHCC Codes Charge Posting Tutorial Coding to Ensure Accurate Health Risk Scoring E & M Codes Tutorial HCC & RxHCC Risk HCC/RxHCC Risk Tutorial ICD-9 Code Training Manual Hepatitis Screening Hospital Based Tools Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial Admission Orders Tutorial Daily Progress Notes Tutorial Care Transition Data Set from PCPI Tutorial Using The Clinic and Hospital Follow-up Call Templates Respiratory Failure Tutorial Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA's Internal HCAHPS Survey Master GP Suite of Templates Master GP Suite of Templates Tutorial Medical Home Support Materials Department of Care Coordination, Director of Care Coordination and Care Coordination Referral Template Electronic Tickler File Electronic Tickler File Tutorial Follow-up Calls Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Services Medical Home Coordination Review Tutorial Medical Home Plan of Care and Treatment Plan Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Patient-Centered Medical Home Annual Questionnaires Patient-Centered Medical Home: SETMA's Medical Home Coordination Review (MHCR) Tutorial Patient Document for Coordination of Care Transitions of Care Management Coding (TCM Code) Tutorial Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial Nursing Home Depression Tutorial Fall Risk Tutorial Hydration Assessment Tutorial Nursing Home Guidelines for Care Tutorial Nursing Home Principal Suite of Templates Nutrition Assessment Tutorial Reduction of Antipsychotic Medications Toolkit Skin Care Tutorial Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds Preventive Health Tools Adult Weight Management Tutorial CHF Exercise Tutorial Diabetic Exercise Tutorial Diabetes Prevention Tutorial Exercise Prescription Tutorial Hypertension Prevention Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Initial Preventive Physical Exam & Annual Wellness Visit Tutorial LESS Initiative Tutorial Progression to Type 2 Diabetes Smoking Cessation Tutorial Progression to Type 2 Diabetes Quality Metrics ACO and Medicare Advantage Stars HEDIS: NCQA, History, Quality, Safety, STARS, ACO ACO Quality Measures Performance Tool ACO Quality Measures Performance Tool Tutorial STARs - A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Letters - Dr. Larry Leibrock – November 28, 2012 -- Follow-up to February 2000 Meeting in Austin

November 28, 2012

Larry Leibrock, PhD
Former Associate Dean
University of Texas School of Business
Austin, Texas

Dr. Leibrock:

In February, 2000, my partner, Mark Wilson, MD, Richmond Holly, SETMA’s CIO, and I, spent four hours with you at the Austin Airport. My closest friend and SETMA’s great friend, Wayne Reaud, arranged that meeting. In August, 2000, I spoke to the Beaumont Chamber of Commerce and I referenced our visit with you:

“Experts have recognized SETMA’s success at applying business principles and particularly “systems thinking” to healthcare delivery. When Dr. Wilson and I spent half a day with Dr. Larry Leibrock, Associate Dean of the School of Business at the University of Texas in Austin, he said, “You have applied business principles to the organization and delivery of healthcare; amazing!” In the July, 2000 issue of Health Data Management, Vinson Hudson, president of Jewson Enterprises, Redwood City, California, who tracks physician practices said: “(SETMA) is not your typical physician practice...Its business model is more sophisticated.” (p 2, Beaumont Chamber of Commerce Address, August 24, 2000, James L. Holly, MD)

What I did not know at that time or at least do not remember knowing is that your area of expertise is technology and that you are heavily involved with forensic technology. The third attachment above is a flyer for a book entitled Innovation with Information Technologies in Healthcare to which I have contributed a chapter I have arranged to have a copy of this book sent to you at: Larry Leibrock, PhD Former Associate Dean, Chief Technologist. If a different address is more appropriate please let me know and I will change the shipping information.

My reason for writing is to express my and Richmond’s gratitude for the time you spent with us in February 2000. Sadly, Dr. Wilson died of pancreatic cancer in March, 2009, but he would share this feeling. Also, I wanted to let you know that shortly after we met with you, we realized that our core competency was not software development but the application of informatics technology to healthcare.

In the thirteen years since we met, we have expanded our use of information technology:

We have invested over $8,000,000 in our systems, all of which is paid. The Return on Investment is incalculable. We use the EHR in the clinic, the hospital, the emergency department, the nursing homes, our homes, physical therapy, etc. While our disease management tools (these can be found under Electronic Patient Management on our website) are robust, few things illustrate how seriously we take healthcare informatics as the description of our security analysis in the two articles whose links are below. Although these articles were published less than two months ago, they are already slightly outdated as things change quickly at SETMA.
Is Your SETMA Medical Record Secure?: Part I
Is Your SETMA Medical Record Secure?: Part II

In May, 1997, SETMA took the first steps to define our “Mission Statement and Strategic Plan”. In that document we defined our intent as to: Maintain the health of our patients; Maintain quality of life for our patients; To do this is in a cost-effective. In retrospect, this sounds very much like the Institute of Healthcare Improvement’s Triple Aim enunciated by Don Berwick in 2008.

As the memo above (Leibrock emrMD minutes of February 23, 2000 Meeting in Austin) reflects, we were considering whether or not to build our own EMR. We quickly abandoned that and focused on what we were good at; designing a healthcare delivery organization based on the business principles of Peter Senge’s The Fifth Discipline. In March, 2011, several of us spent a week with Dr. Senge in Boston. During that meeting, I asked him if SETMA had only co-opted the vocabulary of “systems thinking.” or if our applications of his work was consistent with the principles of “systems thinking?” He affirmed that our use of his work is valid and that it is an accurate application of “systems thinking” to healthcare.
Peter Senge, The Fifth Discipline and Electronic Patient Records

This is a link to a presentation entitled, Peter Senge and EHR, Beyond Electronic Medical Records, Electronic Patient Management and EHR Design, I made at the Texas A&M School of Rural Public Health on January 27, 2011. It is ponderously long but I was given four hours. The doctoral students listened for four hours without a break.

SETMA has been very active in HIMSS. We received the Davies Award in 2005 and our peer reviewed Stories of Success was pubished by HIMSS in 2010. I currently serve on the HIMSS Innovations Committee. The following is a link to a presentation I made in 2006 to the national HIMSS meeting. It summaries our adoption of systems thinking to healthcare. The graphic on Circular Causality is worth the paper and the paper includes “The principles which have guided Southeast Texas Medical Associates' development of a data base which supports these requirements.” Spanning the Specialties to Bring You the Best Standards In retrospect, these ten principles sound very much like the concepts upon which Patient-Centered Medical Home is founded.
SETMA took a Business Intelligence software package and adapted it to healthcare. The following link is to a series of articles on this project which we call SETMA’s COGNOS Project. (we have no disclosures as we own no IBM stock and are not paid by IBM)
COGNOS Project

The fruits of this work are found in the SETMA Model of Care which is posted at

SETMA's Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change

And, in our Public Reporting of Provider Performance by provider name for 2009, 2010, 2011, 2012. The following is a link to that display.

Reporting by Type
On our website, www.jameslhollymd.com, there are tens of thousands of pages of materials which have been published over these years. I have written a weekly newspaper column on health and health affairs for the past fourteen years. All of those columns are published under Your Life your Health. There have been over 150 articles published about SETMA. Those are at In-The-News, along with all of the presentations I have made. Some of the major areas covered in the Your Life Your Health section are:
- Pubic Policy and Healthcare Transformation
- Patient-Centered Medical Home
- Less Initiative (AHRQ has published SETMA’s LESS Initiative on their Innovation Exchange)
- Medical Records

In February, 2011, CMS employed RTI International to examine 312 medical practices who are Patient-Centered Medical Homes and benchmark those against 312 Non-coordinated practices which mirror each of the coordinated practices. They measured Fee-for-service Medicare beneficiaries for cost, quality and coordination. SETMA was superior in all areas. The following is the link to that study.
CMS Medical Home Feedback Report Qualify & Cost

In December, 2011, The Robert Wood Johnson Foundation asked SEMTA to respond to a series of questions about our practice. Through the study funded by RWJF and conducted by the MacColl Center for Health Care Innovation, it is hoped that a tool kit can be developed with will promote transformation in primary care groups across America. 400 practices were nominated and 30 are being selected for analysis. SETMA had a four-day site visit earlier this month. This is a link to SETMA’s 57-page response to the RWJF. The index is made of dozens of hyperlinks which guide you through the document.
The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP): Performance Measures Worksheet - Robert Wood Johnson Foundation

The following is a link to my summary of the site visit. A formal report will be sent to us by the site-visit team in January, 2013.

Robert Wood Johnson Foundation Site Visit Team

The following is a summary of the five major observations of the RWJF team.

“The team identified five areas which were most impressive to them:
- The Care Coordination Department - they had never heard of such a department and had never seen one. They were impressed at how the department is integrated with the clinical personnel through electronic communication and how critical they are to our mission. Across the nation, transformative efforts in healthcare include what is referred to as “daily huddles” - meetings to discuss patient care and the days activities. They were interested in SETMA’s concept of “electronic huddles” where there is continuous communications between departments and colleagues to strengthen, coordinate and improve care.
- The Care Transition and Hospital Care Team -- The complex solutions for this critical area of practice were very impressive to them. The integration of care with the admission hospital plan of care, the discharge Hospital Care Summary and Post Hospital Plan of Care and Treatment plan, the hospital follow-up care coaching call and other aspects of this care transition process, they identified as innovative improvements in the work force relationships among staff.
  The following is a link to SETMA’s submission to the Robert Wood Johnson Foundation of a 120 second video on our Care Transitions for the Prevention of Hospital Re-Admissions Program: SETMA's video submitted to the Robert Wood Johnson Foundation's Video Contest
- The I-Care team - they were very impressed with the electronic tools we have with which to support the work of the full time staff and the professional support staff for I-Care. SETMA has worked in the long term residential care area for its entire existence and before. But, they were impressed with how a group of SETMA providers built upon that foundation and organized an excellent integration of work flow innovations to improve that care.
- Learning Team - they believe that the spontaneous and structured learning of SETMA allows us to continually and almost unintentionally learn and grow. They understand that learning, as Senge says, is only distantly related “to taking in more information.” They believe that we have incorporated “systems thinking” and “systems structures” into SETMA extremely well. They think this is one of the most value aspects of SETMA’s work force and work flow innovations. They were able to attend one of SETMA’s monthly training meetings and were intrigued by the enthusiastic and engaged participation by all of SETMA’s healthcare providers.
“The fifth area of uniqueness of SETMA identified by the RWJF team was a surprise to them; it was SETMA’s IT Department. The team felt that SETMA has approached healthcare transformation differently than anyone they have seen. They related that uniqueness to the decision we made in 1999 to morph from the pursuit of ‘electronic patient records’ to the pursuit of ‘electronic patient management.’ They were surprised to see how centrally and essentially electronics are positioned into SETMA and how all other things are driven by the power of electronics. They marveled at the wedding of the technology of IT with clinical excellence and knowledge. The communication and integration of the healthcare team through the power of IT is novel, they concluded.”

Dr. Leibrock, if you have endured this far and if you recall our meeting, I hope you are encouraged that your four-hour investment contributed to our success. And, if your time and interest allow, we would invite you to visit SETMA as our guest and let us show you first hand our use of technology in transforming healthcare in Southeast Texas.

James (Larry) Holly, M.D.
CEO, SETMA, LLP
www.jameslhollymd.com

About SETMA	In The News	Syllabus PC-MH Externship	Patient Information	Presentations
Governance Board	Your Life Your Health	Public Reporting	Accreditations/Awards	Diabetes Center of Excellence
EPM Tools	Transforming Your Practice Library	Medical Home	I-CARE Initiative	NextMD