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 - Appeal to Medicaid HMOs Regarding their “Personality Rule” for Payment of Claims March 3, 2016

March 3, 2016

Ms. Anne Rote
CEO Molina Health Care of Texas
5605 N. McArthur Blvd., Suite 400
Irving, Texas 75038

Mr. Roland Valle
Amerigroup Provider Relations Vice President
3800 Buffalo Speedway, Suite 400
Houston, Texas 77098

Ms JoLynn Turner
Amerigroup Provider Relations Director
3800 Buffalo Speedway, Suite 400
Houston, Texas 77098

Dear Sir and Mesdames:

As the Founder and CEO of Southeast Texas Medical Associates, LLP (SETMA, www.jameslhollymd.com), I am writing to introduce SETMA and to address one of your policies which is threatening our ability to participate in your health plan. After a brief introduction, below, at the section entitled, “Appeal to Your Health Plan,” I present our request.

SETMA has used electronic medical records (EMR) since 1998. In May, 1999, we experienced a dramatic transformation of our approach to health care with the morphing of our goal into “electronic patient management” (EPM). This transformation arose from our realization that simply creating a patient encounter electronically was an inadequate goal. At that time, we adopted the EPM ideal of using electronics to manage populations, to measure performance improvement and to fulfill what would come to be know as “The Triple Aim” (IHI). Ultimately, this resulted in the defining of SETMA’s Model of Care (see The SETMA Way - SETMA’s Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change). Ten years later, in 2009, this process culminated in our becoming a patient-centered medical home (PC-MH).

In May, 1999, SETMA’s second seminal event resulted from our application of Peter Senge’s The Fifth Discipline to the design of our EMR and our practice. This process defined the principles which guided our development of an EHR and which defined the steps of SETMA’s transformation from an EMR to EPM (Designing an EMR on the Basis of Peter Senge's The Fifth Disciple). These principles also laid the foundation of SETMA’s morphing into a patient-centered medical home (PC-MH). All four May-1999 seminal events are explained in the article at the following link: Your Life Your Health - May, 1999 -- Four Seminal Events in SETMA’s History. The ten principles defined in 1999 were:

Pursue Electronic Patient Management rather than Electronic Patient Records
Bring to every patient encounter what is known, not what a particular provider knows
Make it easier to do “it” right than not to do it at all
Continually challenge providers to improve their performance
Infuse new knowledge and decision-making tools throughout an organization instantly
Promote continuity of care with patient education, information and plans of care
Enlist patients as partners and collaborators in their own health improvement
Evaluate the care of patients and populations of patients longitudinally
Audit provider performance based on endorsed quality measurement sets
Integrate electronic tools in an intuitive fashion giving patients the benefit of expert knowledge about specific conditions

Ten years later these principles resulted in the following accreditations and/or recognitions. SETMA is the only practice in America accredited by all four accrediting and/or recognizing bodies:

NCQA Diabetes Recognition (accredited from 2010-2016) reaccreditation due April, 2016
NCQA Heart and Stroke (accredited from 2013-2016) reaccreditation due June, 2016
NCQA Medical Home (accredited from 2010-2016) reaccreditation due July. 2016
URAC Medical Home and Ambulatory Care (accredited from 2014-2017) reaccreditation due February, 2017
The Joint Commission Medical Home and Ambulatory Care (accredited 2014-2017) reaccreditation due March, 2017
The Joint Commission Laboratory Services (accredited from 2014-2016) reaccreditation due July 2016
Accreditation Association for Ambulatory Health Care (accredited from 2010-2017) reaccreditation due July, 2017

In the fall of 2015, SETMA was invited to participate in CMS’ Transforming of Clinical Practice Initiative (TCPI) which resulted in their request for SETMA to contribute to the tools and library needed for this effort to influence 140,000 healthcare providers transformation of their practices. This material is displayed at www.jameslhollymd.com under “Transforming Your Practice Library.” The following are hyperlinks to the twenty-one sections of the Library.

Summation of SETMA's TCPI Website -- This is an 11-page list of hyperlinks which allow you to easily access the entire library.
Summation of SETMA's TCPI Website in pdf format -- This is a 102-page PDF of the entire library which includes annotated hyperlinks to each section’s content.
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

This information is presented as evidence of our seriousness about excellence in healthcare delivery.

Appeal to Your Health Plan

Recently SETMA became aware that many of our claims from your health plan were not being paid. The reason given was that only the PCP named on the patient’s identification card can see the patient. All other claims are and will be denied.

As a PC-MH, SETMA is aware of the principle of “continuity of care,” both with a robust healthcare data base through an EMR and with a person whom the patient identifies as their PCP. Even though SETMA is a multi-specialty practice with 47 healthcare providers, 67% of the time, we succeed in fulfilling the principle of the patient seeing the same provider. However, it is impossible to do this 100% of the time.

SETMA calls the requirement that a patient be seen by a particular provider, “healthcare by personality.” While this is one element of “continuity of care,” we think that it is an inferior element to a robust, intuitive data base which is accessible at every point of care – all hospitals, all emergency departments, all clinics, and all nursing home. SETMA’s patients’ records are available simultaneously and consistently at all of these places. No matter how well a patient is known by a personal physician, SETMA’s data base is a superior source of patient information needed for the providing of excellent care.

Shortly, after SETMA began using the EMR and before we had access to it in the emergency room, I saw a patient in the emergency room at 5 AM. I had known and treated this patient for twenty years. I knew her healthcare and I knew her stories. When I entered the examination room, the patient pulled out of her purse an printed copy of her most recent visit to my office. It was an extensive medical record. As well as I knew this lady, that document knew the specifics of her health history better than I did. Several years later, I saw two new patients who were sisters and who were related to one of our local politicians. After completing their evaluation, I asked each individually, “Do you think I know enough about you to give you sound advice about your healthcare,” They both said, “You know more about me than the doctor I have seen for twenty-five years. No one has ever asked me that many questions.” Personality is nice; precise healthcare information is imperative.

In May, 1999, SETMA published a booklet entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine: And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management. (see: http://jameslhollymd.com/your-life-your-health/medical-records-more-than-a-transcription-service) This document begins with the following:

“When I was a child, medical records were kept on a 3x5-file card. The information essentially reflected the date and a one-word statement of what transpired in the visit to the doctor, often related merely to a shot or medicine, which was given. Patients paid a dollar for the visit, a dollar for the shot and a couple of dollars for the medication. Expectations were low and expenses were, also. The physician kept most of the important patient information in his/her head. Therefore, when the physician wasn't available, data on the patient wasn't available.

“This system was extremely personal and was often very satisfying for the patient and the physician. When I was born, Dr. Culpepper was my family doctor. In 1949, my family moved and did not use Dr. Culpepper as a physician again. 24 years later, in 1973, when I graduated from medical school, I called Dr. Culpepper and said, ‘Dr. Culpepper, I wanted to say hello and tell you I have graduated from medical school.’ Dr. Culpepper was in his early eighties and said spontaneously, ‘How are Bill and Irene,’ calling my parents by their first names, after not having seen them in 24 years. Dr. Culpepper had a wonderful mind, but it could only be in one place at a time.”

These experiences have helped form my personal healthcare philosophy.

We can assure you that your patients are receiving excellent care. In addition to the above named accreditations, SETMA participates in the Physician Quality Report System (PQRS), is compliant with Meaning Use I and 2 and their successors. Another means we use to prove the quality of our performance is by the Public Reporting of Provider Performance by Provider Name. At the following link, you will find seven years of public reporting of provider performance by provider name on almost 300 quality metrics (Public Reporting - Reporting by Type). We are in our eighth year of this process and we will continue to do so.

SETMA’s appeal is for you to reconsider your rule about not paying for care given by our clinic rather than by a specified provider. We believe your patients’ and your interests are served well by SETMA’s model of care. Please consider our request for you to eliminate the “personality” requirement for the payment of our claims. If you do, we will be delighted to continue to participate in your plan. If you chose not to make this change, we will have to determine whether or not the intrusiveness of your rule is such that it makes us unable to continue in our relationship.

Sincerely yours,

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health Science Center
San Antonio School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

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