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. Ken Shine's note to Dr. James L. Holly - Posted to website with Permission - June 19, 2015

(Dr. Holly addressed three sessions at the Texas Health Home Primary
Care Summit in San Antonio, Texas June 18-19, 2015. Dr. Shine attended
one of these sessions.)

From: Shine, Kenneth Sent: Friday, June 19, 2015 8:58 AM To: James L. Holly

“You are truly a great thinker about health and a leader in health and healthcare!!! I have learned so much from you as have so many others!! I am very proud of your role at UTHSCSA and of the Professorship you have established!!! Keep up the great work!!! Ken” (emphasis added)

Dr. Holly’s note to Dr. Shine -- On Jun 19, 2015, at 8:51 AM, James L. Holly

“Dr. Shine, It is awkward to say this without sounding ingratiating, but I am grateful for your attending and participating in my session this morning. I hold you in the highest esteem and have been pleased to get to know you. Thank you. Larry”

Dr. Bill Henrich’s Note to Dr. Holly concerning Dr. Shine’s note.

(Dr. Shine and Dr. Holly first met when Dr. Shine Chaired and Dr. Holly
served on the Search Committee for a new President of the Health Science Center.
Dr. Henrich was selected as the new President in 2009.)

“Larry, you should save this one. Ken is a person of measured, thoughtful response and his accurate description of you and your many contributions is well deserved. I am just proud to know you. You guys be careful getting back to Beaumont. Let's get together again soon. Love to Carolyn. Bill”)

Dr. Shine’s Retirement Notice

Kenneth I. Shine, M.D.

Kenneth I. Shine, M.D.Kenneth I. Shine, M.D., The University of Texas System’s Executive Vice Chancellor for Health Affairs, and a formidable champion of many UT-led enhancements in health care education and research, has announced his plans to retire from his post in early 2013.

Dr. Shine joined the UT System in November 2003, with a pledge to serve for at least three years. He has now tripled that pledge and in the past nine years has implemented innovative initiatives that will forever leave their mark on the UT System.

During Dr. Shine’s tenure, the Office of Health Affairs has completed six presidential searches, implemented a strategy on the Future of Public Health, launched the nationally recognized Clinical Safety and Effectiveness Program, created the Transformation in Medical Education (TIME) program, established the first Systemwide Academy of Health Professions Educators in the country, and much more. He also led the System as interim chancellor from April 2008, following Chancellor Mark Yudof’s departure, until Francisco G. Cigarroa, M.D., was named chancellor in January 2009.

Last year, Dr. Shine was honored with the 2011 John M. Eisenberg Patient Safety and Quality Award from the National Quality Forum and Joint Commission. He was recognized for leading numerous initiatives to improve quality and safety in health care.

A cardiologist and physiologist, Dr. Shine graduated from Harvard Medical School in 1961. He trained at Harvard’s acclaimed teaching hospital, Massachusetts General, where he became Chief Resident in Medicine in 1968.

In 1969, he joined the faculty at the University of California at Los Angeles, ultimately becoming dean of the UCLA’s School of Medicine in 1986. His leadership helped establish UCLA as one of the most respected medical schools in the country and he promoted major innovations and initiatives in ambulatory education, community service for medical students and faculty, and math and science education in local public schools.

In 1992, Dr. Shine was named president of the Institute of Medicine, a non-profit, non-partisan organization that helps influence national health care policy. Current president, Dr. Harvey Fineberg, said that under Dr. Shine’s leadership the Institute of Medicine took on several crucially important issues such as food safety, tobacco use and end-of-life care and became one of the most important forces to improve health in the nation.

Perhaps the most controversial issue Dr. Shine confronted as president of the Institute of Medicine was the quality of care in America, which led to his landmark report in 2001: Crossing the Quality Chasm €“ A New Health System for the 21st Century. The report found that medical errors were causing tens of thousands of deaths annually and became a powerful impetus for sweeping changes.

He brought that focus on quality to UT System, spearheading a project called Code Red, a statewide call to action to improve access to care, streamline medical education and lay the groundwork for future medical schools in Austin and South Texas.

“One of the greatest privileges I have had as Chancellor is working with Ken Shine. He is a legend in medical education and health care policy. His experience, intellect and drive are unsurpassed,” Chancellor Cigarroa said. “For the past decade, his mission has been: How do we make health care more accessible and affordable for Texans, and how do we better educate doctors, nurses, and health professionals? Patient care is not an abstraction for him. He deeply believes in healing people and saving lives.”

In addition to publishing three versions of Code Red: The Critical Condition of Health Care in Texas in 2006, 2008 and 2012, Dr. Shine and his staff also worked for approval of an 1115 Medicaid Waiver in Texas -- a program which allows states to use federal money to expand and improve health care. The Texas Legislature approved the program in 2011. He also helped establish the Supply Chain Alliance Project, which has saved the UT System more than $80 million and has extended from UT’s six health institutions to nearly all UT campuses.

“Dr. Shine has been a highly respected leader of the UT System health institutions and he has firmly established a national reputation for innovation and leadership,” said Board of Regents Chairman Gene Powell. “He has been tireless in his focus on building medical schools in Austin and South Texas. We will miss his energy, his wisdom, and his guiding spirit.”

Dr. Shine’s indefatigable support for a medical school at UT Austin was instrumental in laying the foundation for the first research-intensive medical school on an academic campus in Texas to become a reality. Though he will retire as executive vice chancellor, he plans to teach at the new medical school, see patients and assist the UT System in any way possible. Travel, fishing and “long postponed” writing are also on his agenda.

“It has been a very rewarding time. I have a group of colleagues in the Office of Health Affairs who are truly remarkable,” Dr. Shine said. “Working with other members of the executive team in UT System and with our presidents has been a joy.”

Related Letters

	Description of November 28, 1998 Testimony to Texas Insurance Commissioner Dr. Ken Shine’s Response After Reading Dr. Holly’s Testimony to Texas Department Insurance (TDI) Commissioner Public Hearing Concerning Physician Compensation, September 28, 1998 Historical Context of Dr. Holly’s Presentation to the Texas Department of Insurance Commissioner’s Hearing, September 28, 1998 Testimony before Texas Department of Insurance Proposed Financial Incentive Guidelines Austin, Texas, September 24, 1998

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