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November 9, 2015
Alicia Caramenico, Healthcare Writer and Editor
I am writing to request an interview for the online publication FierceHealthIT-- which covers health IT news with a focus on EHR adoption, telemedicine, HIPAA compliance. I am writing a special feature article on clinical decision support tools and how they can make for better, faster, more accurate treatment decisions.
I've read about CDS efforts at Southeast Texas Medical Associates (including this piece from the Healthcare Financial Management Association) and would love to hear some of your lessons learned and strategies for success. Could we talk by phone this Wednesday, Nov. 11? I expect to need about 30 minutes of your time.
If that time is not good for you, I’m available any weekday afternoon and can be flexible around your schedule. I’m also happy to send questions to you via email for your convenience. Thanks in advance and I hope to hear from you soon.
I sent an answer back and she responded with the following questions. My answers are associated with the questions.
“Thanks for the quick response - below are some questions that you can answer if you have time before our conversation or we can discuss on Wednesday. And thanks for sending along those articles and notes - they will be very helpful.” Alicia Caramenico
Dr. Holly’s Responses to Ms. Caramenico’s questions in bold face print.
What type of CDS tools does Southeast Texas Medical Associates use? The following are some of the CDS tools which we have developed.
Hospital Based Tools
Did the organization develop its own tech tools or go through vendors? What influenced that decision?
Yes, we built our own tools. SETMA named one of Thirty Exemplary Practices for Clinical Decision Support by the U. S. Office of the ONC for HIT (February, 2011) -- "Advancing Clinical Decision Support" is an intensive, multi-part project funded by the U.S. Office of the National Coordinator for Health Information Technology (ONC) to address the major barriers to achieving widespread use of clinical decision support. The project is being led by the RAND Corporation and Partners Health Care / Harvard Medical School. Rand Case Summary. SETMA named as one of 50 Exemplary Primary Care Practices by the American Board of Internal Medicine Foundation, 2003.
On March 30, 2012, I gave a presentation to the Massachusetts Medical Society, entitled, The Importance of Data Analytics in Physician Practice. (see: http://jameslhollymd.com/Presentations/The-Importance-of-Data-Analytics-in-Physician-Practice; a modification of this address was presented at Grand Rounds at the University of Texas Health Science Center, San Antonio, July 15, 2015 in a different format, see: http://jameslhollymd.com/Presentations/setmas-automated-team-function.)
In Boston, there were three speakers, each had an hour to speak and I was the last speaker. The first speaker asked, “How many tasks can you get a healthcare provider to perform at every patient encounter?” A vigorous discussion ensued at the end of which the speaker said, “I think you can get providers to do one thing.” As the last speaker, I began by saying, “I would like to answer the first speaker’s question, but to do so, you must first answer the following questions”:
- How important is the task you are asking providers to do?
- How much time does it take?
- How much energy does it take?
If you were to create a formula to represent this process, there would be a direct correlation between how many tasks a provider can or will do and how important the tasks are; the more important the tasks, the more tasks a provider will do. There would be an inverse relationship between how much time it takes and how many tasks will be done; the more time it takes, the fewer tasks will be done. There would also be an inverse relationship between how much energy it takes and how many tasks will be done; the more energy it takes, the fewer tasks will be done.
The key to getting more done is to determine what is important and only to do that, and then to make the completion of the important tasks require less energy and less time. Let me illustrate. The Texas State Health Department’s Reportable Conditions illustrates the standardization and the automation of parts of healthcare processes. Remember Peter Senge’s statement in The Fifth Discipline: “The more complex a problem is, the more systemic the solution must be.”
Conclusion:
After the below discussion, which shows that with electronics, many complex and important tasks can be reduced to one second, or no seconds, with little energy expenditure, In he Boston discussion, I concluded: it is possible to get providers to do thirty or forty things every time they see a patient and at SETMA we do.
What results are you seeing from the use clinical decision support tools across the organization in terms in outcomes and costs?
We are seeing dramatic results. See: http://jameslhollymd.com/Your-Life-Your-Health/Abraham-Lincoln-and-Modern-Healthcare
Contained within Abraham Lincoln's famous "House Divided Speech," delivered to the Republican Convention on April, 16, 1856, is the imperative for data analytics and performance auditing by healthcare providers today. Lincoln said, ‘If we could first know where we are, and whither we are tending, we could better judge what to do, and how to do it,’”. (Quoted by David Eisenhower in the Foreword to Churchill: The Prophetic Statesman, by James C. Humes, Regnery, New York, 2012)
In any human enterprise, if the participants are unwilling to objectively and honestly face where they are, it is improbable that they will ever get to where they want to be, let alone to where they should be. CDS has enabled SETMA to fulfill the requirements for Ambulatory Care and Patient-Centered Medical Home accreditation from NCQA (Tier III the highest), the Joint Commission, URAC and AAAHC. CMS audit in 2011 showed SETMA’s cost to be lower (37.1% lower) coordination higher and quality higher the benchmarked practice. See: http://jameslhollymd.com/In-The-News/pdfs/Medical-Home-Feedback-Reports-SETMA-II-102011.pdf.
In December, we finish 7 years of public reporting by provider name on over 300 quality metrics; see: http://jameslhollymd.com/public-reporting/public-reports-by-type.
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.
What would say are keys to successful CDS use? / What are the barriers to using CDS tools to improve care & how is Southeast Texas Medical Associates working to overcome them?
- Barriers to using
- Too complicated and actually take more time than routine care.
- Related to things not very important to outcomes and quality
- Adds significant expense.
- Keys to success - enunciated in May of 1999, four seminal events see: http://jameslhollymd.com/Your-Life-Your-Health/pdfs/may-1999-four-seminal-events-in-setmas-history.pdf. In May, 1999, we defined ten principles of CDS and of Patient-Centered Medical Home; designed from Senge’s The Fifth Discipline, 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
With providers, nurses, pharmacists and other caregivers who are part of a care team getting and using patient data at the point of care, how does interoperability fit into the equation?
The tem principles above address this issue as well. 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 could 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.
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.
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
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