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 - Introduction to SETMA

Introduction to SETMA
November 10, 2016

Inside the notebook given to each participate there was a copy of the Spring, 2015 Vital Signs. A Southeast Texas healthcare publication, there are articles about SETMA on pages 15, 20-21, 36-37 and on the back cover. On pages 20-21, there is a portrait of all SETMA providers and executive management. The following link is to that publication:

http://jameslhollymd.com/in-the-news/pdfs/vital-signs-spring-2015.pdf

Table of Content of the Notebook Given to Conference Participants

They Know What They are Doing and Why They are Doing It!

http://jameslhollymd.com/Letters/pdfs/the-joint-commission-accreditation-for-ambulatory-care-and-pc-mh.pdf

SETMA is accredited by the Joint Commission for Ambulatory Care, Patient-Centered Medical Home and Clinical Laboratory. This is a brief statement about SETMA

SETMA has participated in a Robert Wood Johnson Foundation research project, this is a brief statement from them.

SETMA’s Accreditation - PC-MH, Ambulatory Care, Laboratory, Diabetes, Heart/Stroke

http://jameslhollymd.com/Accreditations/pdfs/accreditations.pdf

SETMA is accredited by multiple agencies. This displays those accreditations and gives the dates of recognition and accreditation.

Testimony before Texas Department of Insurance - September 28, 1998

Text of Dr. Holly’s Testimony

http://jameslhollymd.com/Letters/pdfs/testimony-before-texas-department-of-insurance-proposed-financial-incentive-guidelines.pdf

Description of the September 28, 1998 Event at the TDI Public Hearing

http://jameslhollymd.com/Letters/pdfs/description-of-november-28-1998-testimony-to-texas-insurance-commissioner.pdf

This describes the circumstances of the testimony in III. A. above. The TDI staff, the changing of the time allotment and another Beaumont physicians appearance before the insurance Commissioner.

Dr. Kenneth Shine’s response to Texas Health Home Primary Care Summit, June, 2015

http://jameslhollymd.com/Letters/pdfs/dr-ken-shines-response-after-reading-dr-hollys-testimony-to-texas-department-insurance-commissioner-public-hearing.pdf

Dr. Shine was the Executive Vice Chancellor of the University of Texas System for Health Affairs. This is brief but pointed response to Dr. Holly’s testimony to the TDI Commissioner’s hearing. His response was made 27 years after the hearing.

Dr. Shine’s comment about TDI Testimony

http://jameslhollymd.com/Letters/dr-ken-shines-note-to-dr-james-l-holly

Four Seminal Events - May, 1999

In May, 1999, SETMA experienced four events which turned out to be seminal. The following identifies, describes and explains those events. Every organization needs to be prepared to experience, recognize and recall such events in their development.

Morphing from EHR to Electronic Patient Management

http://jameslhollymd.com/in-the-news/pdfs/setma-1999-four-seminal-events.pdf

http://jameslhollymd.com/Your-Life-Your-Health/pdfs/may-1999-four-seminal-events-in-setmas-history.pdf

Ten Principles for Designing 21st Century Practice

The second event was the result of SETMA’s reading of and incorporating principles from Peter Senge’s The Fifth Discipline. We defined the principles which guided our development of an EHR and which defined the steps of SETMA’s transformation from an EMR to EPM (http://jameslhollymd.com/EPM-Tools/pdfs/designing-an-emr.pdf). These principles would also be the foundation of SETMA’s morphing into a patient-centered medical home (PC-MH). The principles were to:

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

“More Than a Transcription Service: Revolutionizing the Practice of Medicine with Electronic Health Records which evolves into Electronic Patient Management”

http://jameslhollymd.com/Your-Life-Your-Health/pdfs/transcription-more-than-a-transcription-service.pdf

This was a part of our “Cortez Project,” where like the Spanish explorer, we insured success in our transformation by “scatting" our ships,” making it impossible for us to “go back.” Declaring to the community with this booklet, we committed ourselves to success or to humiliation.

Launching of a Celebratory Sprit in SETMA

The fourth seminal event was that we determined to adopt a celebratory attitude toward our progress in EMR. In May, 1999, my cofounding partner was lamenting that we were not crawling yet with our use of the EMR. I agreed and asked him, “When your son first turned over in bed, did you lament that he could not walk, or did you celebrate this first milestone of muscular coordination of turning over in bed?” He smiled and I said, “We may not be crawling yet, but we have begun. If in a year, we are doing only what we are currently doing, I will join your lamentation, but today I am celebrating that we have begun.” SETMA’s celebratory spirit has allowed us to focus on the future through many lamentable circumstances and has allowed us to press forward through many disappointments. Focusing on our successes kept us moving forward and the cumulative effect was always success.

http://jameslhollymd.com/Letters/pdfs/the-joy-of-medicine-the-imperative-of-celebration.pdf

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

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.

http://jameslhollymd.com/In-The-News/pdfs/history-of-setmas-preparation-for-icd-10.pdf

SETMA’s Model of Care

http://jameslhollymd.com/The-SETMA-Way/pdfs/setma-model-of-care-pc-mh-healthcare-innovation-the-future-of-healthcare.pdf

SETMA’s Model of Care has five steps:

Tracking over 300 quality metrics on every patient seen at SETMA
Auditing provider performance by panel of patients or by populations of patients
Statistically analyzing performance looking for leverage points of improvement
Public Reporting on SETMA’s website by Provider Name on the above
Designing Quality Improvement Initiatives from the above data

SETMA’s concepts of ‘Clusters” and “Galaxies” are discussed here.

Business Analytics and Your Analytics Quotient

The materials link in this section address “What If Scenarios,” becoming and being a change agent, “how many tasks can you get a provider to complete at each patient encounter,” the power and promise of data analytics in primary care.

Complete Summary and Annotated Articles Discussing SETMA’s Work on MACRA and MIPS

http://jameslhollymd.com/Letters/complete-summary-and-annotated-list-of-all-24-articles-discussing-setmas-work

SETMA’s understanding, preparation and deployment of solutions for the Medicare Access and CHIPS Reauthorization Act of 2015 with the Merit-based Incentive Plan System. SETMA began using these tools October 1, 2016 in preparation for the 2017 performance measurement reporting.

Four Categories Defined by MIPS 2015 Correlate with Four Strategies SETMA Defined in 2000-2005

http://jameslhollymd.com/Letters/pdfs/four-categories-defined-by-mips-correlate-with-setmas-four-strategies-for-transforming-setma-and-healthcare.pdf

This is an analysis of the relationship between the Four MIPS Categories published in 2015 and the Four SETMA Standards published between 2000-2004. They exactly correlate with one another.

History of SETMA’s Preparation for ICD-10 October, 2015

These documents illustrate SETMA’s “process analysis” which has been at the foundation of our growth and development.

Tutorial for the Automated Team Function

http://jameslhollymd.com/epm-tools/Automated-Team-Tutorial-for-the-EMR-Automated-Team-Function

The “automated team” is the logical extension and actually conclusion to clinical decision support. This document explains and illustrates the function.

Overview and the Philosophical Underpinnings to SETMA’s Offer to CMS’ for the TCPI

http://jameslhollymd.com/transforming-your-practice

In December, 2015, SETMA was invited by CMS to participate in a meeting about the CMS Transforming Clinical Practice Initiative (TCPI).
During that conference, CMS asked the faculty, of which SETMA was one, to provide them with an “Ask and Offer.” The “ask” was what the providers needed from CMS. The “offer” was what could the faculty provider to CMS within 60 days to help with the transformation of the practices of 140,000 physicians. This link is to the materials which SETMA provided to CMS in 45 days.

Addendum

This section is about Hierarchical Condition Codes (HCC) which also includes RxHCC. In our discussion on the 10th, we addressed this. The second document below is a PDF of the first. The PDF has page numbers and on pages 37-41, SETMA’s clinical deployment of HCC Risk Scores is illustrated.

http://jameslhollymd.com/epm-tools/Tutorial-HCC-RxHCC-Risk

http://jameslhollymd.com/EPM-Tools/pdfs/hcc-risk-training-tool-tutorial.pdf

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