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The following comments in red are from James L. Holly, MD’s response to the article below. Dr. Holly has worked with Universal American and its predecessor organization since 1996. The multi-specialty practice which he founded, Southeast Texas Medical Associates, LLP (SETMA, www.jameslhollymd.com) purchased an EMR in 1998. SETMA is accredited as a Patient-Centered Medical Home by NCQA, URAC, AAAHC and the Joint Commission. It is the only practice in America accredited by all four. SETMA is fully integrated with HealthConnect, the Houston based Health Information Exchange. SETMA has been awarded the Davies Award by HIMSS and in 2013 received the HIMSS 2012 Physician IT Leadership Award.
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
Why EMRs won't save health care
Nov 6, 2014, 2:33pm CST Joe Martin Reporter- Houston Business Journal Email | Twitter
Everyone in health care is talking about how electronic medical records are changing the industry - for better or for worse. But if you ask one health care leader, that won't matter if EMRs don't work together.
Interoperability of EMRs (EMRs that work together) is one of the important aspects of ultimately realizing the benefits of EMRs. But even without interoperability, it is a misstatement to say that that they are valueless and that they “won’t matter.” My organization’s history and performance is proof that they do matter. Virtually, everywhere our patients are seen, they are seen with the same, integrated data base.
Technology is a great thing and it can make the industry much more efficient, but right now it's chaos, said Erin Page, president of Medicare for New York-based Universal American (NYSE: UAM), which owns TexanPlus, a Medicare Advantage plan in Houston and Dallas.
The statement that “it is in chaos,” speaking of the effect of technology on healthcare, is categorically not true. Recently, I told SETMA’s providers, at our monthly training session, that “SETMA can do something which it cannot do.” Obviously, that statement was confusing. It means that as SETMA is compliant with Meaningful Use II, we have the ability to transmit our records to other practices electronically in structured data fields. Unfortunately, no one else in our region is able to recevie that material, thus we can do something - send the records - which we can’t do - no one else in our area is able to receive.
That is not chaos; it is progress. The good news is all of our hospitals are participating in HealthConnect so we can share data, but we have been sharing data for 12 years with the hospitals in our area. The bad news is that very few other medical practices are participating.
This articles dramatic statements are good theater but they do not help advance our cause. SETMA has spent over $8,000,000 - none of that paid by the government , agencies, or grants -- and we have transformed healthcare in our area and with our patients. We have work to do, but we have come a longer way. The following statement is included by permission:
“Woodie Woodruff, RN November 5 at 9:06am -- Dr Holly and SETMA have been leaders on the cutting edge of health care in and around our community for many, many years and they continue to set the bar high for others to emulate. No organization has done more for our elderly population than SETMA. As a nurse with over 20 years working both in long term as well as acute care. I commend what they have and continue to accomplish every day.”
In March 1999, we realized that if all we gained from implementing an EHR was an electronic means of documenting a patient encounter, it was not worth the time, energy, effort and cost. If we did not gain the ability to do electronic patient management, then we had made a mistake in undertaking this task. It was then that we realized the power of the tool we had.
We began developing disease management tools and functionalities, which leveraged the capabilities of electronic speed and data analysis. Suddenly, a whole new world opened to us. We examined the problems that were unique to various populations within our practice. One large group of patients commonly experiences five problems: nutrition, hydration, fall risk, skin care and depression. Because simply documenting patient visits in an EHR was an inadequate use of electronic capabilities in the nursing home, SETMA designed tools for evaluating, monitoring and treating these five problem areas and others.
Standardization of quality of care was achieved with guidelines. Analysis of data was achieved electronically to assess the state of hydration, nutrition, the risk for falls, whether skin lesions were preventable or not, and depression. Now we continue to develop new tools for improving data documentation, data analysis and outcomes measurements, achieving in the process the promise of electronic patient management of which we only dreamed in 1999.
In May 1999, we experienced another seminal moment. It taught us to have a celebratory spirit about the development, progress and improvement in our electronic patient management. In that month, my co-founding partner lamented our state of use of the EHR when he said, "We aren't even crawling yet." We started using the EHR Jan. 26, 1999. On the 29th, we used the EHR for every patient, and we have done so since. Yet, even with that success, it did seem that we were not moving very fast.
As I listened to my friend and partner, I said, "When your son turned over in bed for the first time, did you call for your wife and say, 'this dimwitted kid can't even walk, all he can do is turn over in bed?'" He smiled and I continued, "You celebrated his achievement. If a year later, all he was doing was turning over in bed, you would have reason to lament, but for the moment enjoy the progress." I concluded, "If in a year, we are doing no more than we are now, I will join you in your lamentation. But for now, I am going to celebrate what we have achieved."
Through the years, our vision has grown as to what electronic patient management is, and we have celebrated our advances from having the lab interface up and running, to using the EHR in the hospital for history and physical examinations, to creating discharge summaries in the EHR, and now to using the EHR for daily progress notes. We have celebrated the automation of formulas for the calculating the stage of renal disease, Framingham Risk Factors, Cardiometabolic Risk Factors, stages of hypertension, Fredrickson's Classifications of Dyslipidemia, Homeostasis Model Assessment (HOMA) of Insulin Resistance and the list goes on and on and on.
We continue to dream-and some would say hallucinate-and we continue to celebrate. As the old adage says, "We ain't what we was and we ain't what we gonna be, but we're moving forward."
At no point did we experience or were we a part of chaos. We know that in ten years, we will be better than we are now, but we are not going from chaos to organization; we are going from progress to more progress and eventually, we will have extensive interoperability but until we do, we will continue to transform healthcare in our own little world.
One of the biggest challenges of today's industry is the fragmentation of data between all the moving parts of the health care industry, Page said. All the different EMR systems don't directly coordinate with one another, which makes it difficult for a patient's primary care physician to fully understand the scope of a patient's care.
Actually, even in the absence of extensive interoperability, we know by each patient and by populations of patients, the “scope of their care.” SETMA’s Model of Care (see. http://jameslhollymd.com/The-SETMA-Way/pdfs/setma-model-of-care-pc-mh-healthcare-innovation-the-future-of-healthcare.pdf) involves tracking extensive performance by each patient we see every day. There is no chaos and the moving parts are fully integrated. Can it improve? Yes. Will it improve? Yes. What shall we do in the interim? We shall continue practicing excellent medicine knowing that what we consider excellent today will seem inadequate in the future. SETMA’s Automated Team (see http://jameslhollymd.com/epm-tools/Automated-Team-Tutorial-for-the-EMR-Automated-Team-Function) is the future of healthcare and we are practicing it today. The following are hyperlinks to The Automated Team. The names of the hyperlinks outline for the read the elements of our transformation:
This translates to unnecessary or harmful cocktails of medication, as well as inefficient and high costs for payers. But more importantly for doctors, it affects the bottom line in a belt-tightened era of health care.
There is no doubt that interoperability will improve patient safety and the quality of care. Yet, without waiting for the ultimate solutions, SETMA has designed a medical reconciliation program which will solve the problem of “harmful cocktails of medication” - a melodramatic phrase which is clever but not helpful. For the past two years, SETMA has been working on a systems solution (see Peter Senge and The Fifth Discipline) to medication reconciliation. Today, several more pieces of this “modest proposal” are in place. Hopefully, within three or four or more years, what we have designed will be possible, but we will not await ALL of it being present before we do part of it. http://jameslhollymd.com/Medical-Home/pdfs/medication-reconciliation.pdf The progress we have made in medication reconciliation is seen in the Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan which is given to each patient when they leave the hospital: http://jameslhollymd.com/epm-tools/hospital-care-summary-and-post-hospital-plan-of-care-and-treatment-plan-tutorial. The following hyperlinks introduces the subjects covered:
"We have a problem in the industry," Page told me. "It's the cost of health care."
The United States is one of the most expensive and inefficient care countries in the world, And one of the primary reasons for high health care costs, as other health care leaders have said, is the high overheads on the administrative side of the office caused by constant paper shuffling.
The Triple Aim, which is the structure which SETMA uses in pursuing transformation of our healthcare delivery was enunciated by the Institute for Healthcare Improvement in 2008. “Decrease cost” is the third of the three; SETMA chooses to address “sustainability” which includes cost but includes much more. It is easy to criticize our system as the “most expensive and inefficient” as everyone continues to demand more and more care and the latest and fanciest evaluations. The system is made worse by every element of the healthcare system. Yet, with all of our problems our care and outcomes are the envy of the world.
However, EMR systems are expensive. They require overhauls of an office's current system - often simply consisting of a filing cabinet - and training to teach staff how to effectively use the EMR system, which is why doctors are sometimes hesitant to make the switch.
Yes, the best EMRs are expensive and the ones which are inexpensive are not worth having. There is a solution but that will have to await another discussion.
Page compared the health care reform today to the introduction of Medicare. As the program was being implemented, it was chaos. But once the dust settled, it was a success, she said.
I agree. Inherent within the design and deployment of Medicare were the causes of our problems today. Within the design and deployment of the ACA are the next generation problems. Medicare created today’s healthcare problems; uncorrected the ACA will create the next generation of problems we will face.
"It's the most exciting time in health care," said Page.
I totally agree with this statement. By the way, Universal American, Medicare Advantage and Ms. Erin Page are among the “good guys.” With their continued collaboration with healthcare providers, we will see improvements in our system and in our healthcare delivery. We just need to avoid inflammatory and unhelpful language.
Erin Page, president of Medicare at United American
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