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	James L. Holly, M.D.

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Your Life Your Health - A Review of 2010 and a Projection for 2011

James L. Holly,M.D.

December 30, 2010

Your Life Your Health - The Examiner

One year ago tomorrow, our Your Life Your Health article summarized SETMA's expectations for the coming year. As we prepare to think about what we expect to accomplish in 2011, we will first look at our December 31, 2009 forecast of our expectations and see "how we did."

The SETMA Foundation

At the end of 2009, we said, "(this year), The SETMA Foundation matured into a significant force in the lives of our patients...We...experienced remarkable events in our patients' healthcare which would not have been possible without the resources of the Foundation." In 2010, the expanded role of the Foundation was supported by an additional $500,000 contribution by the partners and by our first significant contribution from outside of SETMA. Universal American, our principle HMO partner through Select Care of Texas and Texan Plus, gave a $150,000 gift to the foundation. We intended to have a fundraiser in 2010 but did not get that done. We will hopefully remedy that in the spring of 2011. We continued to see remarkable changes in people's lives due to the funds available through the Foundation. In addition, we saw the funds of the Foundation supplemented by the generosity of the gifts of time and talents from our non-SETMA colleagues in the Southeast Texas medical community.

Healthcare Policy

In "2009, SETMA...participated in the vigorous healthcare policy debate which has taken place in our country.": In 2010, SETMA began participating in plans for launching a new collaboration between health insurance, information technology and private medical practice to demonstrate that the best place for healthcare reformation - really transformation - is the private sector. At the end of 2011, we hope to be able to announce the successful launching of this plan in multiple locations around the nation. As we sat in planning meetings this past year, there was a growing and announced realization that all of the needs for change in the healthcare delivery system in America will be answered by the plans we are making. Ambitious? Absolutely. Impossible? Absolutely not! Unrealistic? Definitely, No! We look forward to being able to report progress and success in this arena.

In the past year, SETMA's story has been told all over America. Other practices continue to come to SETMA to learn about our approach to healthcare informatics and healthcare transformation. In early 2011, SETMA will receive a national award for improving healthcare delivery, the details of which are not able to be announced until January. In 2011, SETMA will participate in the first conference on the use of "systems thinking" produced by Dr. Peter Senge, professor at Massachusetts Institute of Technology (MIT) and author of The Fifth Discipline. Dr Senge's work and the ideas in his book have guided much of the development of SETMA.

Patient-Centered Medical Home

"In February of 2009, SETMA began exploring a new concept called 'Patient-Centered Medical Home.'" In April, 2010, SETMA submitted an application for recognition by NCQA as a medical home and in June, submitted an application for accreditation as a medical home by AAAHC. In July, SETMA received the highest recognition offered by NCQA, Tier III, and in August, we received accreditation by AAAHC for Ambulatory Care and Medical Home. With the creation of our new Care Coordination Department and the employment of the Director of Care Coordination, we continue to deepen our understanding of this aspect of medical home. In 2011, we expect to provide true care coordination with the result of coordinated care to all of our patients.

Joslin Diabetes Center

Additionally, SETMA received recognition for excellence in the care of diabetes from NCQA. In our December, 2010 report, it was stated, "In 2010, SETMA expects to complete the affiliation with Joslin Diabetes Center, which is an affiliate of Harvard University which has been in the planning stages for over two years. The uniqueness of this affiliation with a multi-specialty group has stretched the imaginations of everyone but is soon to be finalized. This affiliation will bring a new energy and dynamic to diabetes care in Southeast Texas."

In August, 2010, we formalized that affiliation. In September, representatives of SETMA attended the orientation and later the annual meeting of Joslin Affiliates in Boston. All of SETMA's providers completed a training program which includes study and testing, writing and presenting case studies on patients we have seen with diabetes (all identification was removed) and finally a four and a half hour discussion with Joslin endocrinologists and staff at SETMA. Now all of SETMA's primary care providers are designated as Certified Joslin Diabetes Center Providers. This is a first for Joslin and is a pattern which is hoped to be replicated all over America.

COGNOS Project

In our 2009 report, we stated: "SETMA chose the IBM Business Intelligence software package, COGNOS, with which to build the capacity to mine our electronic patient records (EMR) for the information needed to measure provider performance and with which to improve patient compliance." We have completed this project and are now routinely using COGNOS to examine our performance in regard to quality standards and the elimination of ethnic disparities of care and opportunities for improvement of our care of patients. In January, 2011, we will begin using our COGNOS Project to examine ways of eliminating preventable readmissions to the hospital.

Quality Metrics

"The generative power of SETMA's EMR has been captured as we have deployed every set of quality measures in existence," we reported in December, 2009. We discovered another which is Bridges to Excellence and in 2010, we deployed BTE multiple quality metrics. In 2010, SETMA also became a formal member of the National Quality Forum which endorses quality metrics used by the entire healthcare community. SETMA representatives attended and participated as expert panelists at a NQF conference on "Care Transitions."

It is noteworthy that SETMA was the only private medical practice in attendance at the NQF meeting. SETMA's achievement n tracking, auditing, analyzing and public reporting of hundreds of quality metrics was acknowledged as remarkable. In 2011, SETMA will consolidate our work in this area and will make certain that this work is "making a difference in the care of our patients."

In 2010, SETMA identified the concepts of "clusters" and "galaxies" of quality metrics. SETMA believes that single metrics will not change health care outcomes but that multiple metrics focusing on a single condition (clusters) and multiple clusters related to a single patient (galaxies) will improve a patient's health.

Website Redesign

In 2010, SETMA completed the redesign of our website to include all of our electronic management tools, SETMA's included material focused on our new I-CARE program, which is an expanded and improved support system for nursing homes, as well as collecting in one place the dozens of articles about SETMA (see In-The-News). In 2011, we will continue to work to make our website more useful for our patients and for our colleagues around the country who continue to express interest in replicating in their communities what SETMA has achieved in Southeast Texas.

SETMA has made much of our work more visible on our website including The SETMA Way, The SETMA Approach and the SETMA Model of Care. Another section entitled "Letters" displays important correspondence which we have had with others about healthcare policy and principles.

Our December, 2009, report stated, "Our website redesign includes a link to NextMD which is our EMR vendor, NextGen, secure and encrypted web portal for patient communication and education." NextMD is now live and being used by our patients. In 2011, we will expand the use of this web portal for secure and confidential communication with all of our patients who use computers.

Public Reporting

In November, 2009, SETMA made a decision to publicly report by provider name our performance on over 200 quality metrics. We have fulfilled that commitment and are expanding the transparency of our work with our patients. Our concepts of "clusters" and "galaxies," defined on our website have guided this development.

Technological Advances

Our 2010 reported stated:

"In 2009, SETMA totally replaced our telephone systems with a new digital system which allows complex analysis of calling activity."
"In 2009, we began placing printers in every examination room so that we could ensure that patients received education materials and evaluational materials such as the LESS Initiative, Disease Management plans of care and treatment plans and in the New Year, a comprehensive coordination-of-care review which will allow patients to know what care they need, what they have received and what remains to be done for them."
In 2009, SETMA purchased the necessary computer software and hardware to redesign our network to improve the efficiency and increase the power of the server farm.

All of these advances are complete and continue to contribute to our progress, in the second year of their deployment.

Health Information Exchange

"In 2009, SETMA obtained licenses from NextGen not only for the previously mentioned web portal, NextMD®, but also for CHS® (Community Health Services®). This NextGen product will allow non-SETMA providers and groups of provides to collaborate on sharing patient-care information, compliant with HIPPA and in a secure, encrypted environment. It will increase efficiency and decrease cost of referrals, communications and repeating of tests."

The HIE now connects SETMA and Baptist Hospital. On January 19, 2011, a community wide meeting will be held with all healthcare providers and organizations to invite them to join and to participate in the Southeast Texas Health Information Exchange. A letter was sent to them last week announcing the meeting. Sponsored initially by SETMA, this effort will be organized and managed by the community, making SETMA one of the first communities in the country to be so organized.

Dr. John Vardiman

Perhaps no person or event more reflects the nature and success of SETMA than the experience of Dr. John Vardiman. In spring, 2010, he finished his 23-year project of building his own schooner - just like the one in which Kevin Costner sailed away at the end of the movie, Message in a Bottle. At its launching his foot was crushed and had to be amputated above the ankle. SEMTA assured Dr. Vardiman that for at least one year his salary and benefits would continue whether or not he could work.

Six weeks later, he asked to make rounds on the weekend with the aid of his grandson pushing his wheelchair. Four months later, he asked to return to the clinic and to practice full time. A challenging set of evaluations and examinations were required and he fulfilled each one excellently. He is now back at work and amazing all of us.

His performance is a credit principally to himself but it is also an honor to SETMA and to the support and encouragement all providers and staff receive through life's crises.

2010

As we review, 2010, with the exception of the fund-raiser for the Foundation, SETMA achieved every goal we established for ourselves and more. It was an exhausting year but a successfully one. We could not be more pleased. These objective evidences of success do not address the subjective ones. The growing cohesiveness of SETMA's staff and the collegiality of all of our providers are remarkable testaments to our success. Only three and a half years since eight physicians left SETMA, we are stronger and more successful than ever.

Yet, we must defer the honor and praise witch we might receive to the goodness of God. The following is worthy of being repeated as it addresses the power and success of SETMA: This is taken from the inauguration ceremony of the Diabetes Center of Excellence Affiliate at SETMA:

"SETMA is a multicultural, multi-ethnic, multi-faith organization, which reflects the people we serve. At this solemn occasion, we cannot omit our acknowledgement of the source of our strength and success. It is, in our judgment, the providence and beneficence of Almighty God. As we sit and stand here, we are Jew, Muslim, Hindu, Buddhist, Christian and perhaps even atheist. Today we celebrate our common commitment to the good of our fellow man, whatever the fount from which that passion flows.

"As we acknowledge God's goodness in human affairs, each of us will do so as we have been taught and as we believe. The exercise of faith by one does not insult nor impugn the faith of another. So, in our pluralistic society, I invite you to pray as you have been taught, as I shall pray as I have been. Whether in your tradition you pray with head bowed and eyes closed, or with eyes open and head elevated, I ask you to join me as I lead us in thanking God for His goodness to us all."

Prayer

"Heavenly Father, in the Name of the Lord Jesus Christ, We thank You for Your goodness to us. We thank You for the life and legacy of Elliott P. Joslin. We thank you for allowing SETMA to be part of an enterprise that brings good to those whom You love and care for. We thank you for our colleagues in the healthcare profession and particularly at the Joslin Diabetes Center.

"We pray for the wisdom and knowledge to give the best care there is to those who deserve nothing less. It is our hope that if we should gather here again in fifty years, we would be able to celebrate improvements in the care of those with diabetes which would be as a noteworthy as the changes for which Elliott P. Joslin and his Center were responsibility in his long and illustrious career. In Christ's Name, Amen."

2011

What is before us in 2011? Some of it has been addressed above. SETMA shall:

Expand the use of NextMD
Expand the HIE to the entire healthcare community which desires to participate.
Expand our use of COGNOS.
Recertify with AAAHC.
Apply for and receive Meaningful Use certification by CMS.
Complete plans for "5010" a new billing program mandated by CMS.
Complete plans for fulfilling "ICD-10" and SNOMED.
Respond to increasing numbers of physicians who wish to join SETMA. We welcome all who wish to participate collaboratively for the success of our patients and community.
Continue our advances in quality care.
Continue to transform the delivery of healthcare and to support others who wish to do the same.

In December, 2011, we shall see how we have done.

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