Many challenges face Southeast Texas’ healthcare delivery system.  Some of them are:

1. Healthcare for the uninsured or the underinsured - the present system is antiquated, inefficient, expensive and inadequate.
2. Access to timely emergency healthcare - the present system is expensive, time consuming and inadvertently promotes irresponsibility on the part of patients, who, failing to establish a relationship with a healthcare provider, overwhelm emergency services for non-emergency problems.  With four to eight hour waits for care in emergency departments, patient risk increases.
3. Healthcare cost as a factor in the Southeast Texas business market.  Major contracts have been lost to Southeast Texas because of the healthcare cost factor which made bids by Southeast Texas companies non competitive with other regions of the country.
4. Maintaining the quality of healthcare while controlling the cost of that care for our Senior citizens and for others on fixed incomes.
5. Integrating the delivery of healthcare where patient data is shared among all providers giving that care.
6. A current healthcare system, which is excellent in the quality of care it delivers, but is unprepared for managing the challenges of the future.
7. A growing understanding of the health hazards related to environmental and occupational considerations.

If we accept the validity of these issues, how do we solve them?  I once thought that people studied business because they couldn’t do any thing else.  Then, I started reading business literature and discovered a world of intellectual acumen and expertise equal to science, mathematics or any other academic pursuit.

Systems Thinking

A book, which has influenced everything we do at Southeast Texas Medical Associates, LLP, is Dr. Peter Senge’s The Fifth Discipline, in which he declares, “The more complex a problem, the more systemic the solution must be.” Senge has reference to “systems thinking,” which is a way of organizing analysis of complex problems in business enterprise.   Systems thinking is:

• A discipline of seeing wholes
• A framework for seeing interrelationships rather than things
• For seeing patterns of change rather than static ‘snapshots.’
• A set of general principles spanning fields as divers as the physical and social sciences, engineering, and management.

System thinking is needed more than ever because for the first time in history, humankind has the:

• Capacity to create far more information than anyone can absorb,
• To foster far greater interdependency than anyone can manage
• To accelerate change far faster than anyone’s ability to keep pace.

Complexity can easily undermine confidence and responsibility and systems thinking is the antidote to this sense of helplessness that many feel as we enter the ‘age of interdependence.’

SETMA Has Adopted Senge’s Ideas

SETMA has applied Dr. Senge’s ideas to the private practice of medicine because the practice of medicine and healthcare delivery are so complicated today they require systems solutions.   And, the only solution to the issues facing Southeast Texas in healthcare delivery is “systems thinking” and “systems solution.”

Experts have recognized SETMA’s success at applying business principles and particularly “systems thinking” to healthcare delivery.  When Dr. Wilson and I spent the day with Dr. Larry Liebrock, 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.”

Southeast Texas Medical Associates’ Strategy

Three years ago, Dr. Mark Wilson and I determined to transition our practice from a paper/document medical record to an electronic/data medical record.  We didn’t know it then, but what we were doing was embarking on a journey of “systems thinking” and “systems solutions” in healthcare delivery.

In the past five years, Southeast Texas Medical Associates has committed its future to two beliefs, both of which reorganized our thinking about healthcare delivery:

1. Managed Care strategies can provided excellent care to our patients while helping control the cost of that care.
2. Electronic Medical Records is the only methodology and/or technology, which can make this happen at the provider level.

Once you get by the methods of managed care:

• Precertifications,
• Limited provider panels,
• Formularies,
• Authorizations,
• Referrals, etc,

you are left with its dynamics which are:

1. A continuum of Care model of delivery, which addresses the quality component of the value equation, and which is a data issue.
2. An integrated delivery network organization of that delivery, which addresses the cost component of the value equation, and which is also a data issue.

This dynamic requires a different kind of medical record than that which has traditionally been available.  In the history of medicine, the nature of medical records have been:

1. In the 18th Century, for practical purposes, medical records -- as a documentation of individual patient treatment -- did not exist.
2. In the 19th Century, medical records were not much better, but those that existed were based on pencil and paper.
3. In the 20th Century, the standard of excellence for medical records was transcription.  This was a vast improvement, but fundamentally employed the same methodology as the 19th Century -- paper.  Fundamentally, 18th, 19th and 20th Century medical records were documents.
4. In the 21st Century, medical records will be based on some form of electronic medical records.

Transactional and Static Medical Records

19th and 20th Century medical records, except for research programs, were essentially transactionally driven.  When a patient “showed up” a record of the transaction between the provider and the patient was made.  And, that recorded remain in the providers office unless it was physically transported somewhere else.  FAX machines allow us to provide “real time” access to records from remote sites, but that access remained static.  There was no dynamic interaction with the patient’s record anywhere.

This is going to change in the 21st Century, as providers are going to:

1. Think about his/her patients when they don't show up.
2. Interact with their patients in a real-time continuum of care model of healthcare delivery. Which is responsible for both quality and cost.
3. Not only going to have to think about their patients when they are not "there," they are going to have to think about them as: a person, a population, a problem (disease state), and a preventive healthcare opportunity.  This kind of strategic thinking about our patients when they are not in our office or on our phone will require:  Systems which provide Data over time and which is Accessible,.

These systems, this data and this accessibility will guarantee that we will function with both a continuum of care and in an integrated delivery network.

Limitations of Old Document-based System of Medical Records

The limitations of the old document-based system and/or of any new system which principally depends upon a document, even if that document is electronically generated, are illustrated by:

1. If a drug were recalled, there was no effective way of determining which patients were on the drug therefore being able to notify each one to stop it, and to call the office for a substitute.¹
2. There was no systematic way of seeing how many patients with diabetes and hypertension were on an ace inhibitor, which is protective of renal disease.²    The same applied to many other disease states.
3. There was no effective way of continually bringing the family, social and past medical history forward in the chart to make it an interactive part of every patient encounter.³
4. There was no way of determining how many patients had not had a pap smear, mammogram  or occult blood screen, short of asking those questions when the patient came for a different illness.⁴    Therefore, preventive healthcare was driven by acute healthcare, which essentially didn’t work.  And, even when the provider kept excellent records,  there was no way to access  that information short of picking up and examining each patient record.
5. If the healthcare provider were at a different location than where his/her charts were stored, the  paper chart, no matter how extensive and well organized, was little improvement over the 3x5 card.  The patient and provider were dependent upon the memory of the provider for continuity of care.⁵
6. Patient allergies, drug interactions and the use of drugs in certain disease states were  dependent  upon  the  physician’s  knowledge  and/or  memory,  not  on  the interactivity of various capacities of the medical record.⁶
7. Everyone wanted quality in healthcare, but it was difficult to define and almost impossible to prove.⁷

Systems Thinking, Results in Integrated Healthcare Delivery Networks (IDN) Integration of healthcare in to delivery networks:

1. Produces collaboration between every person participating in the care of a patient and the sharing of information on that patient at every point of the patient’s entry into the healthcare system.
2. Demonstrates that the primary care physician and the specialist have common goals and incentives, and that they share the same information about the patient.
3. Provides that the home health agency, hospice, DME, physical therapy, reference laboratory and  long-term care facility have a common vision and a seamless interface when dealing with the patient.

The IDN model is realized when each member of the healthcare delivery team has access to the patient’s  record and when the patient’s record is updated and available to other members of the team at and  from  every encounter with another IDN team member. Without this sharing of information, at best the patient’s care will be segmented and inconsistent.

Continuum of Care Model

What truly differentiates a continuum of care is that care management drives patient care. And, care management is a database function.  If the patient’s record is available at every point of contact with the healthcare system, there will not be:

• Redundancy - repeating the same test or procedure simply because one healthcare provider does not know that another provider has the information.
• Inefficiency  -  collecting the same information  about  the patient  -  past  medical history, family  history, etc. - multiple times simply because there is no effective means for sharing that information from provider to provider.
• Excessive cost - A plan of care has always been a part of healthcare.  Sometimes that plan of care will be treatment and instruction to return if the patient doesn’t improve; sometimes it will be referral to a specialist, and sometimes it will be observation and testing if the patient doesn’t recover.  Whatever the plan of care, it should be:

• Documented - CPR allows this to be done every time.
• Discussed with the patient - CPR allows for this to be documented every time.
• Followed - CPR allows the provider to follow-up the patient, even if the patient doesn’t keep his/her follow-up visit.

• Defensiveness - the best defense against an accusation of inadequate or substandard care is a complete history and physical and an agreement between the provider and the patient as to a plan of care.  CPR allows the provider to document a plan of care with which the patient agrees.  When that plan is based on sound medical judgment and an excellent record, the need for excessive and often expensive tests to prevent lawsuits will be eliminated.
• Lack of follow through - Patients often discontinue treatment and/or fail to seek follow-up when  they begin to feel better.   CPR allows the provider to track patient follow-up and to make certain  the patient’s treatment or evaluation is completed. With  CPR,  SETMA  has  designed  an  electronic  tickler  system,  which  allows consistent follow-up on patients who require further, essential testing or repeat testing.  For instance, if a person needs a follow-up chest x-ray in six months, SETMA has an electronic solution for reminding the patient and the provider to make sure the test is done.

The IDN  will  have  elements  of  the  insurance,  care-delivery  and  continuum-of-care models, but preventive care, health promotion and community health will drive the care delivered by an IDS.

SETMA Moves Toward an IDN

The reality is that whether a family physician, a cardiologist or an endocrinologist, the initial information needed on a patient is the same:  chief complaint, history of present illness, review of systems, allergies, past medical history, family history, social history, and habits.   If this information  can be shared, it will make the IDN more efficient and more effective, and that will increase the excellence of the care.

Information systems also enable the healthcare provider to drive the delivery process because  of the  data,  which  is  available.  Traditionally,  healthcare providers  only responded to the care request of their patients.  Now, providers can structure and deliver preventive care and routine care, which is more cost sensitive and higher quality.

Healthcare driven by the provider is:  higher quality, more cost-effective, preventive and more effective.  The only way the healthcare provider can drive health care is with records, which give him/her the capacity to:

• Measure outcomes,
• Monitor preventive care and
• Make patients’ healthcare database available at every point of the patient’s access to healthcare.

Healthcare driven by the patient is:   typically more expensive, poorly managed and thereby less effective.  Also, healthcare driven by the patient is typically based on static

medical records, which are driven by acute medicine, rather than health maintenance and preventive care issues.

Constable or Counselor?

Healthcare providers must never lose sight of the fact that they are providing care for people, who are unique individuals.  These individuals deserve our respect and our best. Healthcare providers must also know that the model of healthcare delivery, where the  provider  was  the  constable  attempting  to  impose  health  upon  an  unwilling subject, has changed.  Healthcare providers progressively are becoming counselors to  their  patients,  empowering  the  patient  to  achieve  the  health  the  patient  has determined  to  have. This  is  the  healthcare  model  for  the  21st  Century  and  the computerized patient record is the tool, which makes that model possible.

Providers and patients being collaborative in the patient’s health initiatives is a data driven dynamic and it requires the sharing of that data between patient and provider.

Managed Care:  Realities, Rights & Responsibilities

Managed Care focuses attention on the three categories related to each party in the healthcare delivery equation.  They are “realities,” “right” and “responsibilities.” Managed Care is the free-market’s response to the realities of the healthcare industry.

Three Fundamental Questions Which Face All OF Healthcare

The first reality is that there is no possibility of healthcare financing and management ever returning to the laizze faire style practiced up until twenty years ago.  Someone is going to control and manage healthcare.  The only real question is, “Who?”

1. The financing of healthcare will never return to a system where the medical decision making process takes place in isolation and independent from the question of “Who is going to pay for the services?”

The second reality is that because of the expense of technology and because of increasing access to healthcare by a larger population, it is possible for healthcare alone to bankrupt the United States government.  Unchecked, the cost of healthcare delivery can prevent
the balancing of the Federal budget.

2. The financing of healthcare will never return to a system where the medical decision making process takes place in isolation and independent from the questions of, “How much is a service worth and how much is society willing to pay for it?”

This expense produces the third reality, which is that there are limited resources to continue to provide the excellent healthcare, which the citizens of this country presently receive.  Someone has to allocate those resources.  The question is “Who?”

3. The financing of healthcare will never return to a system where the medical decision making process takes place in isolation and independent from the question of, “What is society’s responsibility to its most vulnerable citizens as far as access to affordable healthcare is concerned?”

The fourth reality is that the government has assumed, by law, the responsibility of providing healthcare to a certain segment of our population, and the government is not going to surrender that responsibility.  The facts of this reality are explained by the AAPCC - the Actual Average Per Capita Cost.  This is a calculated figure based on HCFA (Health Care Finance Administration) payments for healthcare in the United States.  It is calculated on a county-by-county basis for every county in America.   The AAPCC is higher in Southeast Texas, which means that the cost of healthcare per capita is higher here than in most places in America.

In the private sector, the principle is the same.  While there is no Trust Fund, private companies have budgets and must meet them.  Managed care allows industry to budget its healthcare costs by transferring the “risk” to another company.  In order to remain competitive, private industry must control healthcare “risk.”

The second relevant issue is “responsibility.”

Each “player” in healthcare delivery today is in an unspoken partnership, which has actual and implied responsibilities.

• Payers (managed-care companies),
• Providers (physicians and other deliverers of health services) and the
• Patients (insured).

Each “player” has its peculiar responsibilities.  The payers, of course, have responsibility for operating within the “realities” of the AAPCC and/or contract, and for making sure that access to healthcare is maintained.  Balancing these responsibilities is a function of the core values and integrity of the managed-care company and of HCFA regulations. Providers are responsible for providing outstanding care.  In managed care, healthcare is more directed toward preventative healthcare than to treating a problem, which has already developed.  Physicians’ must be aware of the differences in cost for care.  The reality is that care obtained at one place, which is equal to the quality of care obtained at another, can be three times as expensive.  To conserve the healthcare resources for the benefit of everyone, the physician’s responsibility is now, not only to assure quality, but to consider cost-effectiveness as well.

The patient has responsibilities in the managed-care system as well.  In order to get the expanded benefits and cost decrease of managed-care, the patient is responsible for utilizing physicians who have contracted with the managed-care company and who are committed to complying with utilization management guidelines, pre-certification of

procedures and review of care.  The patient also has a responsibility to avoid habits, which cause increased health problems when and where possible, and to cooperate in obtaining preventive care, which can decrease the cost of maintaining health before serious and costly problems develop.

The Third Relevant Issue is Rights:

Within these “realities” and “responsibilities,” what are the patients’ and providers’ rights?  The patient has the “right” to excellent healthcare and to have access to needed care.

However, the rights of the patient must be balanced with the rights of the managed-care company and with the rights of the healthcare providers who provide care.  Likewise, the rights of these latter two groups must be balanced against and with the rights of the patient.  The patient has the “right” to choose any PCP (Primary Care Provider) who is in the contracted network of the managed-care company and/or for the IPA (Independent Physician Association).  And, the patient has the right to go to any specialist who has agreed to cooperate with the managed-care company.

But, the patient’s right to choose his physician cannot interfere with the right of the managed-care company to manage the “risk,” which it has assumed.  The patient has the right to request that their favorite physician contract with the managed-care company. But, the physician has the right to refuse.  And, the managed-care company has the right
to expect the patients and providers to comply with the utilization management guidelines and standards required to manage effectively the “risk” the company has assumed.

Providers have rights also.  Most physicians have resorted to demanding their right to lead health care management.  The new realities result in that demand being rejected. If providers wish to exert influence over the delivery of healthcare, they will have to accept their responsibilities and collaborate with payers and patients.

Changing Accountability

New standards of care are being enunciated by:

1. HEDIS, The Health Plan Employer Data and Information Set, which is the National  Committee on Quality Assurance’s standardized set of about sixty performance measures  for  managed care plans.   It has become the industry standard and is at the core of most health plan report cards being developed all across the United States. It is the standard  against which all healthcare providers are going to be judged.
2. The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, including health maintenance organizations (HMOs). It is governed by a Board of Directors that includes employers, consumer and labor representatives, health plans, quality experts, regulators, and representatives from  organized medicine.   The NCQA indicates that within two years, they are going to be offering NCQA certification to individual medical groups as well as to health plans. The time will come when NCQA certification will be a critical component for success in the emerging medical marketplace.
3. National Standards of Care are going to apply - not only in lawsuits, as they are now - but  in provider evaluation and contracting decisions.   More and more, in addition to board  certification, clinic performance as measured by these standards is going to be the entrée to participating in heath plans, as well as board certification.

Critical performance indicators, such as HEDIS, national standards of care and NCQA certification are going to be increasingly used as measures of clinical performance.8 Computerized Patient Records can be utilized not only to meet these standards of care, but also to prove that they are being met.

In the 20 months that SETMA has been using EMR, we have had five HEDIS audits, all of which have resulted in a superior rating.  We are gradually building national standards of care guidelines into the database of our EMR.   In all of these areas:

• NCQA Certification
• HEDIS audits and/or compliance
• Medicare audits and/or compliance
• National Standards of Care

CPR is the only record keeping and patient management tool, which can solve the complex problems facing healthcare providers in the 21st Century.

The Issues Facing Southeast Texas

The solution to all of the healthcare issues facing Southeast Texas, whether the uninsured or those on fixed incomes, whether integration of the delivery network or the solving of emergency care issues, are so complicated today they require systems solutions.

• Without the ability to track HEDIS data, it will be impossible to “prove” that you are doing quality work.
• Without the ability to examine patterns of behavior among the providers in your group, it will be impossible to improve the quality of care.
• Without being able to monitor the behavior of your patients, it will be impossible to affect the health of a population of people.

Without systems, none of these things can be done effectively.  In the future, primary care doctors are going to be a cross between clinician, counselor, epidemiologist, and business man/woman.  To integrate each of these functions, without neglecting the attention, which the individual patient deserves, systems are going to have to carry the burden of the capturing, documenting and the analyzing of the data necessary to accomplish each of these functions.

Selling A Systems Approach to Healthcare Delivery

Once a healthcare provider has been “sold” a systems approach to healthcare delivery, the sells task has only begun.  Any successful implementation of a computerized patient record requires the “selling” of the idea to several different groups.  SETMA has never stopped this selling process to our:

• Providers,
• Patients
• Payers
• Community.

SETMA’s patients now expect to have a record, which is complete, accurate and accessible.  Their expectations are such that quality care for them begins with the capturing of precise and accurate data about their healthcare events whether in the clinic, on the telephone or in the hospital.  SETMA’s healthcare providers now expect to challenge every patient with preventive healthcare issues many of which are irrelevant to the event which precipitated the current encounter, but each of which addresses long-term health needs of every patient.  SETMA’s customers, the payers, who pay our charges, are coming to expect the kind of documentation which gives them the ability to properly access the quality of care and appropriateness of care which their membership is receiving from SETMA providers.

The selling of a systems approach to the process of healthcare delivery not only encouraged each participant in the healthcare process to “buy in” to the concept, but it also put SETMA in the position of “having to” succeed.  Once we announced that we were going to do CPR, and once we “bragged” on what it would accomplish for our practice and our patients, we had no choice but to succeed.  Selling the CPR is not unlike the Spanish Explorer, Hernn Corts (1485-1547)who arrived on the Yucatan peninsula in the year 1519.  One historical account relates the events:

“The Spanish soldiers were divided between their desire for fame and wealth and their fear of defeat and death. ‘We're only 500,’ they told Cortez, and he answered, ‘Then our hearts must be doubly courageous.’ ‘We are dying of fevers and Indian attacks,’ others complained. ‘Then let us bury our dead at night so that our enemies will think that we are immortal.’

‘Let us go back to Cuba, let us sail back,’ others said in frank mutiny. ‘But there are no ships,’ Cortez answered, ‘I have sunk the ships, right here. There is no way but up, there is no retreat. We must go forward to Mexico and see if this great Montezuma is as great as he proclaims himself to be.’ So, the soldiers cheered and acclaimed Cortez as their leader, and all cried ‘Forward, to Mexico, to Mexico!’”

Cortez insured the success of his mission by making it impossible for his troops to retreat. He burned the ships.  In many ways, the “selling of the CPR” is like that.  It makes going back impossible and makes going forward to success the only alternative.

The Information Systems Department

Whether the IS Department is one person who “knows more about computers than others,” or is a fully equipped department with network and systems engineers, the issues are the same.  The IS Department exists for the support of healthcare delivery.  The goals and objectives of each IS Department must be spelled out, but some are generic:

1. To facilitate the effective and excellent treatment of all patients.
2. To securely store all patient records.
3. To make the patient records available at ALL times, with minimal, if any, interruptions because of system complications.
4. To make all changes and/or upgrades to the system at times when there is minimal need for the records, i.e., after-hours and/or weekends.
5. To have a “can do” mentality about solving new problems and/or providing new functionalities for the system.

The IS Department exists for the care of patients, not the care of patients to support an IS Department.  While this distinction may seem trivial, it has tremendous practical implications.

Interim Judgment of A Systems Approach to Healthcare Delivery

It is the future and the future is now.  There is no way to do managed care effectively without systems and there is no way to meet the documentation and preventive care demands of all health plans in the future without CPR.  If healthcare is going to be driven by the provider, it is going to be so because of excellent records and particularly excellent Histories and Physicals.  The only way both to integrate healthcare databases and to utilize that database at every patient encounter is with CPR.

Now that SETMA is virtually paperless, we find ourselves to be more efficient and more excellent in all areas of our practice.  Without CPR, we could not be consistently performing at the level, which has become the acceptable standard in our practice.

CPR is not easy to implement, and it is not easy to modify an existing practice to comply with Managed Care principles, but the two compliment each other and make it possible to be successful in the new healthcare environment.

In closing, let me share with you a quote from a young attorney with whom I shared the idea of “sinking your own ships,” as a metaphor for implementing CPR at SETMA. Speaking of the Cortez story, he said:

“I have always loved that analogy.  I was wondering if other doctors realize the implications of what SETMA has done.  By showing that it is technologically attainable to have a paperless office, with electronic safeguards against giving contraindicated medicines and losing or misplacing files, you have in essence raised the standard.  Doctors with paper files can no longer claim to be acting prudently, when information is missed due to legibility or misplacement of paperwork, since there is an available cost-effective alternative.

“As an example, plaintiff lawyers typically compare a company with an unsafe working condition to DuPont, which has some outstanding safety procedures and a good record, to the chagrin of other industry.  SETMA may find itself being the ‘DuPont’ of med/mal cases in the future.

“You have burned your ship, but I wonder if your colleagues realize that their sails are on fire as well?”

Southeast Texas Strategy for Success

Collaboration between business, hospitals, healthcare providers, insurers, media, patients, and governmental agencies will allow Southeast Texas to:

1. Recognize that our sails are on fire,
2. Devise a plan for success,
3. Burn our ships,
4. Move successfully into the 21st  Century

With a healthcare model which will enable us to:

1. Remain competitive in attracting new business enterprises to Southeast Texas
2. Allow those businesses to remain competitive in winning new contracts
3. Maintain the excellent quality of healthcare which our citizens now receive
4. Control the cost of that healthcare.

That is why Southeast Texas Medical Associates, LLP has developed a strategic partnership with Memorial Hermann Baptist and with Channel Four television to provide integrated healthcare services to Southeast Texas.  One of these is First Nurse which is a twenty-four hour a day, seven day a week, telephone triage program which allows anyone to call and get qualified counsel about acute healthcare problems.  And, if the patient does not have a relationship with a private healthcare provider, First Nurse will arrange one.  If the patient does have a healthcare provider, First Nurse will transmit the information from this contact to that provider for follow-up.

Southeast Texas is the first region of its size to have such a service.  In partnership with Channel Four and Memorial Hermann Baptist, Southeast Texas Medical Associates continues to think systemically about healthcare, maintaining quality while controlling cost.

Vested Interests Often Resist Solutions

Nevertheless, there are many “vested” interests in Southeast Texas, which make solutions more difficult to implement:

• Politicians often refuse to address issues because of fear of not getting reelected.
• Physicians often resist change for fear of losing control of their practices and/or losing income.
• Patients often refuse innovation because the unknown is always threatening.
• Employers, driven by a survival instinct, want quick fixes to their insurance cost, often without regard to long-term implications.
• Human Resources departments want no complaints from their employees regardless of the cost making innovation difficult.

These are real and understanding concerns, but if we want a “systems wide” solution, we must get past these parochial perspectives, to find global solutions.  For those of us who have lived more than half of the Twentieth Century, Pogo is a cartoon character we knew well.  And, Pogo, as a philosopher often told the truth.  His wisdom applies to the issues facing healthcare delivery in Southeast Texas in the 21st  Century, for as Pogo said, “We have met the enemy and he are us!”

We, the members of the Beaumont Chamber of Commerce and the members of the business and economic community of Southeast Texas, hold the key to successfully meeting the challenges we face.  The only questions that remain are:

• Do we have the resolve to look at the whole rather than our small part?
• Do we have the resolve to accept solutions, which in the short term may require sacrifice on our part?
• Do we have resolve to accept nothing but real solutions?
• Do we have the resolve to work until we do solve these problems one at a time?

I believe we do.  On October 19th, the Chamber is sponsoring the first of a series of all day workshop sessions to begin examining and solving specific aspects of this whole.  I hope that you will participate.  SETMA will be there and we will come with the resolve to be a part of the solution, rather than simply continuing to contribute to the problem.

James L. Holly, MD Managing Partner
Southeast Texas Medical Associates, LLP
www.jameslhollymd.com

1. Recently, both Rezulin and Propulsid have provided our practice the opportunity to search our records and to notify each patient on these drugs as to how they should proceed. Several weeks, before this conference, our local newspaper had an article about a danger of Plavix. That same day, we mailed a letter to all of our patients on Plavix explaining to them what they should do and whether they should continue the medicine or not.
2. SETMA is now able to do this and has begun disease-state management strategies to improve the compliance and health of our patients.
3. SETMA now requires that every provider review these at every visit and we audit charts to make sure that this is being done.
4. SETMA has designed Access reports to examine each one of these issues and others, based on HEDIS and NCQA standards.
5. All of SETMA’s providers now have high-speed Internet access from their homes in order to respond to patient inquiries after hours and on the weekend. Also, SETMA is capturing in the CPR all patient telephone calls and the responses to those calls (over 190,000 incoming calls per year).
6. With CPR, these functions are now automatic and do nor depend upon the memory of the provider. This gives the patient confidence that their medications are safe when they take them and when they are taken together.
7. The ability to examine the preventive health initiatives of a practice and the ability to examine compliance with national standards of care, along with NCQA and HEDIS standards moves SETMA toward the day when it will be possible to “prove” that we are providing superior care. Additionally, the auditing and “grading” of each providers performance on the CPR is another quality measure,  which insures that our patients are receiving quality healthcare.
8. The following is one of the standards, which NCQA has established in regard to the signing of medical records.  It demonstrates how specific the standard is and how electronic medical records meet those standards.  HEDIS states:  “For medical record entries dated after July 1, 1999, NCQA will not accept stamped signatures as appropriate author identification. However, NCQA will continue to accept handwritten signatures, unique electronic identifiers, and initials.”  For more information on both HEDIS and NCQA see  www.ncqa.org.