- You have an extraordinary passion for your practice, your patients, and you pursuit of excellence. Where does that passion come from?
- You built your own Electronic Health Record system at SETMA. Why did you feel the need to do that?
- Your Community Council gives your patients a very strong voice in SETMA governance and operations. Were any of your staff or doctors worried about that when you first set it up?
- You and your team have successfully earned recognition/accreditation already from AAAHC, NCQA, The Joint Commission, and URAC -- which is a lot of work -- and you’re now looking at Planetree. Anybody there getting “accreditation fatigue”?
- What advice do you have for practices that want to begin (and continue) the transformation journey to become a patient-centered medical home?
- Finally, tell us something about yourself that few people would know.
My father did not go to college but started work as a laborer with Louisiana Power & Light Company. In 1947, when I was four, we moved to a company house at Camp Livingston, a decommissioned military base outside of Ball, La. My family of four shared a two-bedroom house with another family. My father traveled to Monroe, Louisiana every Monday morning and returned Friday night. Within a year, he ran the power station and we moved to Natchitoches, Louisiana where he ran the power company’s interests over a large part of north Louisiana including Camp Polk which would become Fort Polk. Graduate engineers were sent to him for training. I watched his drive and energy and his commitment to excellence without supervision and without guidance. I saw rich, educated and powerful men defer to my father because of his character and drive. I learned.
Years later, I was riding down an unpaved, country road with my father when he stopped his truck and yelled to a man plowing in the field. John Tom walked over and my father said, “I thought you were going to be by the house last Friday?” John Tom said, “One of the kids got sick but I’ll be there this week.” As we drove on, I asked my father what that was about. He said, “John Tom couldn’t pay his light bill and I paid it for him.” This was Louisiana and my father was Caucasian and John Tom was African-American. I learned. He would never let children go without heat and power. Although he made less than $5,000 a year, he was never without money to help others.
As my social liberalism grew, my father expressed concern. He had lived his life one way but had never opposed his culture, as I started doing aggressively when I was 17. I told him, “Daddy, everything I believe and everything I do, I learned from you.” As my personal faith grew, it only reinforced the lessons I had learned from my father until I would define myself as “a social liberal, a fiscal conservation and a theological fundamentalist. “ My father is deceased but I still live with a desire to be like him, to be a man of integrity, honor, compassion, and of fearlessness.
The other great influence on and driver of my life is the overwhelming gratitude which I feel toward my society and my profession for the honor of being a physician. I still stand in awe of having the privilege of being a physician. As I watched and re-watch the movie Secretariat, I am moved almost to tears at the portrayal of his running of the Belmont Stakes in 1973. After a brief moment, he is no longer running to beat other horses. He is running for the sheer joy of running. Secretariat is competing only with himself and his achievement was breathtaking. I realized the reason I was drawn to this race is that I have come to the point in my life when I am working for the sheer joy of my work. I have frequently said, “I have a passion for which I am owed no credit and over which I have no control as it is a gift from God.”
In the movie Saving Private Ryan, Ryan, now in his seventies, approached the headstone of Captain John Miller who gave his life that Ryan could live. In perhaps the most poignant moment in a great film, tears stream down his face, as Ryan plaintively said to his wife, "Tell me that I have lived a good life; tell me that I have been a good man." The sacrifice of others, imposed upon Private Ryan a debt only a noble and honorable life could repay. My debt did not originate so dramatically but it still exists.
There are few gifts as great as that of the opportunity to be a physician. The trust of caring for others has always been a sacred trust. It is a trust which should cause each person so honored to tremble with fear that he/she will not have lived worthily of that honor. It should cause us to examine our lives for evidence that we have been good stewards of the treasure of knowledge, skill, experience, and judgment which has been bequeathed to us by our university, our professors and the public which funded our education.
What nobler calling could one have than the opportunity to collaborate with others in their quest for health and hope? The honor of trust and respect given by strangers, who share their deepest secrets, knowing they will be held sacrosanct, is a gift which exceeds any pecuniary advantage. The pursuit of excellence in the care of others is a passion which is self-motivating.
Passion is the fuel which energizes any noble endeavor. It is what makes a person get up early in the morning, work hard all day, and go to bed late at night looking forward to the next day. It is a cause of great sadness that today's society is so devoid of true purpose-driven passion. Many only vicariously experience passion through the eyes and lives of athletes, movie stars, or musicians. Ultimately, passion and purpose are what make life worth living. Those of us, who have been allowed the privilege of being physicians, can and should know the passion of a noble purpose every day of our lives.
The greatest gift I have been given is passion for my patients, my practice and for the pursuit of excellence. The details of this story can be found at:
In October, 1997, SETMA attended the Medical Group Management Association (MGMA) meeting to preview electronic-health-record (EHR) solutions. In March, 1998, SETMA signed a contract with an EHR vendor. We deployed the enterprise practice management (EMP) side of the system in August, 1998 and the EHR on January 26, 1999. By Friday, January 29th, we documented every patient encounter in the EHR.
In May, 1999, four seminal events transformed SETMA’s healthcare vision and delivery. First, we concluded that EHR was too hard and too expensive if all we gained was the ability to document an encounter electronically. EHR was only “worth it,” if we leveraged electronics to improve care for each patient; to eliminate errors which were dangerous to the health of our patients; and, if we could develop electronic functionalities for improving the health and the care of our patients. We also recognized that healthcare costs were out of control and that EHR could help decrease that cost while improving care. Therefore, we began designing disease-management and population-health tools, which included “follow-up documents,” allowing SETMA providers to summarize patients’ healthcare goals with personalized steps of action through which to meet those goals. We transformed our vision from how many x-rays and lab tests were done and how many patients were seen, to measurable standards of excellence of care and to actions for the reducing of the cost of care. We learned that excellence and expensive are not synonyms.
Second, from Peter Senge’s The Fifth Discipline, we defined the principles which guided our development of an EHR and the steps of our practice transformation from an EMR to electronic patient management (EPM); they 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
In 2009, we would discover that these principles are essentially the principles of patient-centered medical home (PC-MH) and that the past ten years had prepared SETMA to formally become a patient-centered Medical home. Between 2009 and 2014, SETMA would become accredited as a medical home by all of the organizations offering recognition or accreditation for medical home: NCQA, AAAHC, URAC and The Joint Commission.
The third seminal event was the preparation of a philosophical base for our future; developed in May, 1999, this blueprint was published in October, 1999. It was entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine With Electronic Health Records which Evolves into Electronic Patient Management”.
As we began defining and developing critical supports required for success in Performance Improvement, we found them to be:
- Care where the same data base is being used at ALL points of care.
- A robust EHR to accomplish the above.
- A robust business-intelligence analytics system, which allows for real-time data analysis at the point of care.
- A laser printer in every examination room so that personalized evaluational, educational and engagement materials can be provided to every patient at every encounter, with the patient’s personal health data displayed and analyzed for individual goal setting and decision making.
- Quality metric tracking, auditing and statistical analysis.
- Public Reporting of quality metric performance by provider name.
- Quality Improvement initiatives based on tracking, auditing and analysis of metrics.
- Shared vision among all providers, support staff and administrators - a personal passion for excellence -- which creates its own internalized, sustainable energy for the work of healthcare transformation.
- Celebratory culture which does not compete with others but continually improves the organization’s own performance, using others as motivation but not as a standard.
- Monthly peer-review sessions with all providers, to review provider performance and to provide education in the use of electronic tools.
- Adequate financial support for the infrastructure of transformation.
- Respect of the personal value of others and the caring for people as individuals.
- An active Department of Care Coordination and a hospital-care support team which is in the hospital twenty-four hours a day, seven days a week.
- Aggressive end-of-life counseling with all patients over fifty, and active employment of hospice in the care of patients when appropriate.
Fourth, my co-founding partner lamented 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 started. 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.” These four seminal events have defined SETMA’s EMR pilgrimage and are the foundation of our success.
To transform our delivery of healthcare required that we design and build our own EMR as no existing EMR shared our vision, philosophy and goals.
Our staff had no more anxiety about involving our patients in the governance and operations of SETMA than our patients had have in involving us in their health care decisions. This was a reflection of SETMA’s mission statement, which declared: “To build a multi-specialty clinic in Southeast Texas which is worthy of the trust of every patient who seeks our help with their health, and to promote excellence in healthcare delivery by example.” Our patients have to trust that we have their best interest in heart and we have to do the same in trusting them. In exercising that trust SEMTA has the control and guidance of our three standards of decision making which are legality, morality and ethicality. We will do anything they asked, as we will do anything we judge to be good for them, as long as it is legal, moral and ethical. We are in the early stages of the development of the full potential of the Council but so far it has posed no risk to our commitments, values or standards.
Yes, we did experience “accreditation fatigue” after completing the first four in a twelve-month period. We did not pursue Planetree immediately after completing The Joint Commission in March, 2014 because of that “accreditation fatigue.” Because we renewed NCQA and AAACH and gained initial accreditation from URAC and The Joint Commission from July, 2013 to June, 2014, future renewals of all four will always occur in a 12-month time frame. We are addressing future risks of fatigue by the development and maturing of our accreditation team and by practicing a plan of continuous review of our compliance with all elements and standards of all four organizations. Not only does that continuously improve our march toward a true PC-MH delivery model, it also updates our performance when the standards and/or requirements of any of the accreditations change. Thus when it is time to renew our accreditations, it will simply be part of our routine work plan.
PC-MH recognition and accreditation are worth the process, the price, and the pain. We believe that PC-MH is the future of healthcare, and it is possible to be part of that future now. It is not easy to transform a practice into a medical but it is not impossible. A practice with the goal of being a medical home should measure success by their own advancement and not by whether someone else is ahead of or behind them. In the same way, they must share their success with others. Remember, recognition and accreditation are valuable but ultimately it is the cultural change which will make a difference.
The following steps will help:
- Determine where you are and where you want to be.
- Select the template or model you will follow.
- Outline the steps you will take.
- Develop a timeline for completing each task.
- Be innovative. Emulate the best of others, but expand upon the work and make it yours.
- Be patient but eager.
- Enjoy what you are doing and celebrate where you are.
- Be relentless; don't give up.
I am fundamentally a lazy person and my raw intellectual capability is far below the performance level we maintain. I attribute the differential to the providence of God. But, I do have what Peter Senge in The Fifth Discipline calls Personal Mastery which is described by ten principles:
- The have a special sense of purpose that lies behind their vision and goals. For such a person, a vision is a calling rather than simply a good idea.
- They see current reality as an ally, not an enemy. They have learned how to perceive and work with forces of change rather than resist those forces.
- They are deeply inquisitive, committed to continually seeing reality more and more accurately.
- They feel connected to others and to life itself.
- Yet, they sacrifice none of their uniqueness.
- They feel as if they are part of a larger creative process, which they can influence but cannot unilaterally control.
- Live in a continual learning mode.
- They never ARRIVE!
- (They) are acutely aware of their ignorance, their incompetence, and their growth areas.
- And they are deeply self-confident!
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