February 10, 2016

Kathleen Kimmel
Nurse Consultant
Office of National Coordinator HIT HHS

Ms. Kimmel: 

Thank you for your very kind note.  The article you referenced, “Automated empathy allows doctors to check on patients daily,” is very interesting. SETMA has an automated function which allow us to contact patients by various electronic means as well as by telephone for personal health, population health, quality initiatives and compliance. 

The ONC staff to which I referred in Tuesday’s call was Mat Kendall.  I have also had extensive contact with Kevin Larson.  These are two e-mails from Mat.

From: Kendall, Mat (HHS/ONC)
Sent: Thursday, February 24, 2011 3:50 PM
To: James L. Holly
Cc:
Subject: RE: Thank you

Dr. Holly,

Thank you so much for the articles.  I’ve been reviewing them (and you great website) with my team and we are extremely impressed with the work that you are doing.  I was wondering if we could work with you on our Meaningful Use Vanguard (MUV) project.  MUV is our way of working with the Regional Extension Center to identify providers who are already using HIT to the fullest extent.  Our goal is to showcase them and use their experience to help make the transition for other providers that aren’t as far along.  I’m ccing Kyle Nicholls, our MUV Coordinator and David Bergman, the REC project officer for Texas, who can provide you with more information about the program.  I’m also trying to schedule a trip to Texas later this year and schedules permitting would love to come by your practice and see things in action.

Take care and thank you so much for your leadership/inspiration.  Sincerely, Mat Kendall, Director of the Office of Provider Adoption Support (OPAS)

This is Mat’s note following my presentation to ONCin 2011 which is referenced below.

-----Original Message-----
From: Kendall, Mat (HHS/ONC)
Sent: Thursday, March 31, 2011 2:54 PM
To: James L. Holly
Cc:
Subject: Thank you

Larry,

I just wanted to thank you for taking the time to enlighten the folks here at ONC about the work that you are doing.  It truly is revolutionary and I'm confident that it is fundamentally changing the health care that your patients are receiving.  I hope that through ONC's collective work we can increase the number of other providers who share your zeal for using information to positively improve the health care of their patients.  You are an inspiration.

Thanks, Mat, Mat Kendall, Director of the Office of Provider Adoption Support (OPAS)

Part of SETMA’s culture is reflected in the following review of our preparation for ICD-10.  The importance of this is not the subject but the process and particularly the process analysis and the celebratory spirit we have.  The paragraphs below are copied from the following link; the concepts are key to our work.

Letters - The Joy of Medicine - The Imperative of Celebration:: The History of SETMA’s Preparation for and Journey to ICD-10 -- the following, taken from this link, helps explain why SETMA can produce a document for almost everything we have every done in transforming our practice of healthcare and why all of those documents are publicly available at no cost.

Why Write About Meeting ICD-10 After you have done it? - The History of SETMA’s Preparation for and Journey to ICD-10

“On October 1, 2015, as 12:05 AM, SETMA successfully deployed ICD-10.  All 47 healthcare providers used the system successfully immediately.  All nurses and staff did the same.  All interfaces and clearing houses worked well and charges were successfully sent to health insurance companies on the same day.  The task is done; so, let’s move on to the next, but it is not done.  A complex task, which has been called the biggest thing to happen to American healthcare, and it has been a “non-event” at SETMA.  All is moving smoothly; in fact, SETMA’s providers really like ICD-10 and see it as a great improvement in documentation. 

“Why then do we stop and look at what brought us to this event successfully?  One of the reasons is that that it is what brings ‘Joy to healthcare colleagues.’  Stopping, if only for a moment to remember and to celebrate creates focus and energy for the future.  So it is that we published the following piece on October 5, 2015:  History of SETMA’s Preparation for ICD-10.

“As we review the history, we review SETMA’s Your Life Your Health article published on October 1, 2015:  History of SETMA’s Preparation for ICD-10.  This is our explanation to our patients and community about the reason for and benefit of ICD-10.  It is as the French would say, “the raison d’être,” - the “reason for being” of ICD-10.  We review the Beaumont Enterprise article to which SETMA contributed, entitled, “Will Codes Affect Care”:  Health: Will codes affect care?.

And, in reviewing these three documents, we celebrate and in that celebration we find the passion, the energy, the resilience to face the future.  We remember, April 12, 2007, when we were told, “Today is a watershed; in six months SETMA will no longer exist.”  We remember that six months and six years came and went and SETMA prospered and grew.  We remember the reasons for this were our mission and our vision and the blessing of Providence.  We are humbled and we are encouraged.”

Our communications with ONC and with CMS are reflected in the following links and materials:

1. Presentations - The Future of Healthcare: Address to the Patient-Centered Primary Care Collaborative Stakeholders’ Workshop, March 30, 2010 -- this link is to the slide deck which I presented to ONC on March 31, 2011 at the ONC offices in Washington, D.C.
2. Letters - An Appeal to CMS and ONC for a Temporary Exemption to Meaningful Use 2 -- An Appeal to CMS and ONC for a Temporary Exemption to Meaningful Use 2 (Subsequently we fulfilled the requirements without an extension)  The following is taken from this link and addresses key aspects of who we are and why we have succeeded. 
   
   

   “This correspondence is an appeal from Southeast Texas Medical Associates, LLP (SETMA, www.jameslhollymd.com) in Beaumont, Texas, in regard to Meaningful Use 2 (MU2).  It is founded upon SETMA’s vision for transformation of healthcare, which is the path for dynamic and sustainable change.  Internalized values, a personal and collective vision and a generative passion for excellence in healthcare delivery are the fuel and energy for transformation in medicine.  Reform is dependent upon external pressure, based on rules and regulations to sustain and guide change.  Reform requires financial reward and/or threat of financial penalties to drive the process, while transformation is driven by a creative tension between one’s vision and one’s current reality.  CMS and ONC will want to take care that attempts to improve care with reform does not adversely effect dramatic improvements through transformation.

   “Not being inherently creative, reform is dependent upon uniformity with all participants being required essentially to look alike; transformation will result in sustained, creative innovation, which will by its nature result in diversity.  Transformation will be trail blazing with rapid innovation producing advances in healthcare improvement.  Sometimes, reform will stifle creativity and transformation.  To avoid this potential negative impact of well-intentioned reform, thoughtful leaders will recognize the need for innovative leaders and organizations to receive temporary exemptions from the rules and regulations which are the tools of reform. (For more on the dichotomy between reform and transformation see Healthcare Policy Issues Part III - Reforming or Transforming Healthcare.

   “SETMA shares CMS’ and ONC’s desire for improving the patient’s experience of care, for improving the outcomes of care, and for making those changes sustainable.  We also believe in transforming healthcare through the creative use of technology and innovation.  We recognize that one of the frustrations with transformation by public policy leaders is that it is, by necessity, more difficult to control and to measure.  While our appeal has a broader intent than to address SETMA’s circumstances in regard to MU2, it is based on who we are, from where we have come, and where we wish to go.”

3. Letters - CMS/OINC Health IT to Support ACO and Group Reporting" The Past, The Present, The Future -- CMS/OINC Health IT to Support ACO and Group Reporting" The Past, The Present, The Future - the following is a brief introduction to “The Automated Team” from this link.

“Genesis of an Idea, May, 2013 - The Automated Team

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

What can we do today in healthcare which would mirror the changes IBM experienced?  How can we change ‘collaterallists’ into ‘collaborativists’?  How can we use the power of electronics, analytics, and informatic principles to energize radical change to create a new future in healthcare?  Testing and measurement is a science.  In most industries, quality is determined by testing performance.  But, in healthcare we are involved in a new kind of “testing.”  The tests used to measure the performance of healthcare providers are unique.  Therefore, if you are going to measure the quality of care given by healthcare providers.

4. Letters - Letter to CMS Staff of April 23, 2015 ONC/CMS Joint Meeting Requesting Introduction to Person or Department to Discuss CMS Compliance with Physician Hospital Team Membership - October 27, 2015 -- Letter to CMS Staff of April 23, 2015 ONC/CMS Joint Meeting Requesting Introduction to Person or Department to Discuss CMS Compliance with Physician Hospital Team Membership - October 27, 2015
   
   

   “Our medical community is having a discussion about the participation of RNs on hospital care teams organized by physicians. The following is a link to my Open Letter to the Medical Executive Committees of two local hospitals:  Letters - An Open Letter to the Medical Executive Committees of Baptist Southeast Texas Hospital and Christus St. Elizabeth Hospital.  The article at this link is arranged with fifteen hyperlinks which makes accessing the material easier.

   “The crux of the issues is that based on a CMS audit in 2013 and on the recommendation of consultants who are called, “CMS Consultants,” both hospitals are verging on restricting RNs from working with physicians in the hospital.  Because we have reviewed our model of care and have been assured that it meets all standards and compliance issues, we expected to be “ok.”  Now we are told that exceptions cannot be made for anyone, even if we have addressed and responded appropriately to the concerns expressed by CMS in 2013. 

   “I am seeking an audience with the appropriate person or department at CMS or HHS to discuss this issue and to clarify exactly what CMS expects.”

5. SETMA’s Solution for CMS and ONC Meeting on Health IT to support ACO April 23, 2015 - the following is the outline and hyperlinks to the content of the notebook prepared by SETMA for this conference.
   

   “The following are SETMA’s solutions for these tasks:

   • The Primary Care Team:  Learning from Effective Ambulatory Practices (PCT-LEAP) Performance Measure Worksheet - Robert Wood Johnson Foundation tma.com/letters/Robert-Wood-Johnson-Foundation-PCT-LEAP

   This is a copy of SETMA’s submission to the Robert Wood Johnson Foundation for SETMA’s participation in the LEAP Study conducted by the MacColl Institute.  This material covers data aggregation and principles of quality metrics and their limitations.

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

   This is a description of SETMA’s Model of Care which describes the five principles of that model and it describes SETMA’s data capture, and provider Feedback and engagement.

   • ACO Quality Measures Performance Took and A New Tool for Assessing Depression in all Patients 18 & Older  

   Specifically addresses ACO Measures Capture and Aggregation

   •   Value-based Payment models, Last Group of Questions:
   
   
   1. Why is capitation with fixed monthly payments a viable value-based payment model?
   2. Does capitation give physician practices a transformational edge by allowing flexibility to redesign care crafted to the local market?
   3. How can you use PCMH to generate value-based payment opportunities and revenue gains?
   4. Does EMR-based tracking of quality metrics help support advancement and adoption of evidence-based medicine?
   5. Mindset shift: A value-based healthcare industry will be financially lean relative to the healthcare industry’s longtime volume-based business model. How do you convince physicians to embrace value-based care and payment vs. volume-based care and payment?
   
   
   • Value-Based Payment Models, Questions for the Industry, HealthLeaders Media, Answers by James L. Holly, MD, April 2015

   Eight questions about value-based payment models:

   1. What are the key factors for physician practices to consider when weighing involvement in value-based payment models?
   2. Industry-wide, gauge the trend for physician-practice uptake of value-based payment models?
   3. How do you organize physician practices to embrace value-based payment models? At physician practices, are there particularly daunting hurdles to adoption of value-based payment models?
   4. At SETMA, how have your clinical models of care changed to match value-based payment models?
   5. At SETMA, have value-based payment models driven down service volume? If utilization rates have declined, what impact has that had on the practice? If there has been a negative impact, did you find ways to offset that impact?
   6. At SETMA, what are the prime ways you are using data in conjunction with value-based payment models?
   7. How does changing from “volume” to “value” payment models affect measurement of patient experience of care?
   8. What are the essentials of value-based payment reform?
   
   
   • Inside the back cover of the notebook: Public Reporting of Provider Performance on Quality Measures -- Public Reporting - Reporting by Type

If you have gotten this far, you have more endurance than most.  SETMA has produced for CMS’ TCPI program, the following material to help others understand the transformation process.  This link is to the introduction:  Transforming Your Practice - Introduction to SETMA’s TCPI Library

1. The Introduction to SETMA's TCPI Library, this is the one-page introduction which you are presently reading.
2. The second section is entitled Transforming Your Practice (TCPI) -- this is the overview and philosophical underpinnings which is SETMA's "offer" to CMS for the TCPI Initiative.  It is an 88-page introduction to the site (see Transforming Your Practice in pdf format). Pages 49-88 is an annotated list of the content of the library.  
3. Summary To Entire TCPI.  This a two part summary of the entire library:

1. Summation of SETMA's TCPI Website -- This is an 11-page list of hyperlinks which allow you to easily access the entire library.
2. 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.

The following are links into the remaining 19 sections of the library:

1. CMS Quality 12.2015 TCPI
2. Leadership and Governance
3. Care Coordination
4. HIPPA and Security
5. Data Analytics
6. Care Transitions
7. LESS Initiative
8. Medical Records
9. Clinical Decision Support
10. Hospital Care Tools
11. Disease Management Tools
12. Preventive Health Tools
13. Behavioral Health
14. Transformation Tools
15. New Transformation Tools
16. Patient-Centric Care
17. Nursing Home
18. Medical Home
19. Display and Explanation of SETMA’s Patient-Centered Medical Home Tools
20. The final subject is an introduction to our foundations from 1999 which can be reviewed at: Your Life Your Health - May, 1999 -- Four Seminal Events in SETMA’s History

•  SETMA is in our eighth year of public reporting by provider name on over 300 quality metrics --  Public Reporting - Reporting by Type

• We also do "real time" self examination similar to what PCPI intended, allowing providers to see their performance at the point of service.  The following describes that process -- Letters - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP): Performance Measures Worksheet - Robert Wood Johnson Foundation

I look forward to future contact as your interests and needs direct.

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