JamesLHollyMD.com

	James L. Holly, M.D.

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Letters - Letter to Sherril Gelmon, DrPH - OHSU & PSU School of Public Health

May 31, 2018

Sherril Gelmon, DrPH,
OHSU & PSU School of Public Health,

P.O. Box 751, Portland, OR 97207-0751

Dr. Gelmon:

I read with great interest your article, “Strategies for Addressing the Challenges of Patient-Centered Medical Home Implementation: Lessons from Oregon.” Your use of Peter Senge’s The Fifth Discipline mirrors our experience at SETMA.

Southeast Texas Medical Associates (SETMA, www.jameslhollymd.com) has been accredited for PC-MH and ambulatory care (http://jameslhollymd.com/accreditations) by:

NCQA (2010-2019),
Joint Commission (2014-2020),
URAC (2014-2017,
AAAHC (2010-2017).

In our development since 1995, we have depended heavily upon the principles of Peter Senge’s The Fifth Discipline. Several years ago, I visited with Dr. Senge in Boston and asked him, “Have we just coopted your vocabulary and applied our dictionary or have we accurately understood and applied the principles of “the Fifth Discipline.” His response was, “You have accurately understood and applied the Fifth Discipline.”

I read Peter’s book in 1995 and did a 50-page outline which has formed the basis of our use of his work. In 1999, two years after adopting EHR, I wrote 10 principles for designing an EHR the Fifth Discipline. In 2006, I gave an address at HIMSS on the application of Senge’s work. In 2011, I gave a seven-hour lecture at Texas A&M Rural Public Health doctoral program on the applications of Senge’s work in healthcare. In 2009, we began the process of transforming to a PC-MH model and discovered that the principles we had identified in 1999 applied perfectly to PC-MH. I have attached below the links to these documents.

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

This summary of four seminal events which occurred in 1999 which defined SETMA’s progress. The second of the four was the enunciation of the ten principles from Senge’s work

This presentation was made at HIMSS in San Diego in 2006. It addresses the material developed in 1999.

http://jameslhollymd.com/Presentations/The-Fifth-Discipline-and-Electronic-Patient-Records

This presentation was made at Texas A&M University School of Rural Public Health in 2011. This slide deck is 159 slides long. I did speak for seven hours without a break. The students were all PhD candidates and no one left.

http://jameslhollymd.com/your-life-your-health/pc-mh-setmas-first-nine-years-continuity-creativity-consistency

In February, 2017, I wrote a nine-part summary of our pilgrimage. The logical connection between each step of our journey is clear and explains the stability and energy of our practice.

As SETMA prepared for MACRA and MIPS, we discovered a correlation between the four strategies which we defined for the transformation of healthcare and the four categories for evaluation by MIPS.

The four categories defined by MIPS in 2015 correlate with the four strategies SETMA defined in 2000 for the transformation of our practice. In 2000-2005, SETMA established the belief that the key to the future of healthcare transformation was an internalized ideal and a personal passion for excellence rather than reform which comes from external pressure. Transformation is self-sustaining, generative and creative. In this context, SETMA believes that efforts to transform healthcare may fail unless four strategies are employed, upon which SETMA depends in its transformative efforts.

On October 6, 2016, I realized that SETMA’s four strategies correlate with CMS’ four categories for the determination of MIPS’ Composite Performance Score. In bold face below, SETMA’s four strategies for healthcare transformation are listed; following that in red are the MIPS categories which correlate with SETMA’s strategies.

SETMA’s Four Strategies for Healthcare Transformation - MIPS Four Categories of Scoring System

The methodology of healthcare must be electronic patient management - MIPS Advancing Care Information (an extension of Meaningful Use with a certified EMR)
The content and standards of healthcare delivery must be evidenced-based medicine - MIPS Quality (This is the extension of PQRI which in 2011 became PQRS and which in 2019 will become MIPS -- evidence-based medicine has the best potential for legitimately effecting cost savings in healthcare while maintaining quality of care)
The structure and organization of healthcare delivery must be patient-centered medical home - MIPS Clinical Practice Improvement activities (This MIPS category is met fully by Level 3 NCQA PC-MH Recognition).
The payment methodology of healthcare delivery must be that of capitation with additional reimbursement for proved quality performance and cost savings - MIPS Cost (measured by risk adjusted expectations of cost of care and the actual cost of care per fee-for-service Medicare and Medicaid beneficiary)

The logical extension of these correlations flow from our philosophy and our integration of IT and our practice. These innovations were acknowledged by the Joint Commission and the Robert Wood Johnson Foundation.

The Joint Commission Accreditation for Ambulatory Care and PC-MH Conclusion about SETMA

Both the surveyors and one of the executives at The Joint Commission commented about the philosophical foundation of SETMA’s work. Wednesday afternoon (March 5, 2014) I called my executive contact at The Joint Commission. He said “I was just talking to one of my colleagues and showing him SETMA’s notebook which was prepared in response to The Joint Commission’s Standards and Requirements Chapter Seven o leadership.” The executive said, “Look at this; everything they do is founded upon a philosophical foundation. They know ‘what they are doing,’ but more importantly, they know why they are doing it.’” SETMA is not the result of random efforts but of innovations and advances which are consistent with a structured set of ideals, principles and goals.

It is helpful that The Joint Commission recognized this and commented upon it. It is one of the strengths of SETMA and it is one of the principle guides to SETMA’s development history, i.e., what caused SETMA to become what it is.

Robert Wood Johnson Foundation LEAP Study conducted by the MacColl Institute

The fifth area of uniqueness of SETMA identified by the RWJF team was a surprise to them; it was SETMA’s IT Department. The RWJF team felt that SETMA has approached healthcare transformation differently than anyone they have seen. They related that uniqueness to the decision we made in 1999 to morph from the pursuit of “electronic patient records” to the pursuit of “electronic patient management.” They were surprised to see how centrally and essentially electronics are positioned into SETMA and how all other things are driven by the power of electronics. They marveled at the wedding of the technology of IT with clinical excellence and knowledge. The communication and integration of the healthcare team through the power of IT is novel, they concluded.

This year, I reach my 75th birthday. After 45 years of practicing medicine, I am approaching the end of my career. My only regret is that I will not be able to see what PC-MH will become over the next 45 years. Your article assures me, however, that advancements will continue.

Thank you.

James L. Holly, M.D.
CEO, SETMA

409 504-4517

Adjunct Professor
Department of Family and Community Medicine
UT Health San Antonio
Joe R. and Teresa Lozano Long School of Medicine

Associate Professor
Department of Internal Medicine
Texas A&M University
School of Medicine

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