SETMA employs four elements in transforming healthcare and we believe these elements are the core to any sustainable, affordable and acceptable healthcare transformation:

1. The Substance -- Evidenced-based medicine and comprehensive health promotion
2. The Method -- Electronic Patient Management
3. The Organization -- Patient-centered Medical Home
4. The Funding -- Capitation with payment for quality outcomes

Evidence-based medicine must be the substance of healthcare. All care must be tied to proved therapeutics, treatment guidelines and pharmaceuticals. Anything, such as Chiropractic care must only be paid for if there is scientific evidence of its effectiveness. The reality is that if a therapy is legal, even if it is not evidence-based, it can be received by a patient. However, insurance and particularly publicly-supported insurance payments must not be used for such treatments. Patients can pay for anything legal and ethical, but the government must pay only for what is evidenced-based, no matter who the provider.

Electronic patient management (EPM) is different from electronic patient records (EHR). EHR is a method for documenting a patient encounter; EPM is a method for leveraging the power of electronics to produce better outcomes and better health. EPM includes integrating quality metrics, data analytics, clinical decision support and clinical process support into the healthcare process. An extension of EPM is the transparency of public reporting of quality performance by provider name. And, it involves fulfilling the contract with patients which states, "If you make a change; it will make a difference."

These parts of the equation for successfully transforming healthcare will not happen automatically. The principles which SETMA enunciated in 2000 for the development of our EHR are:

The principles which have guided Southeast Texas Medical Associates' development of a data base which supports these requirements are:

• Pursue Electronic Patient Management rather than Electronic Patient Records
• Bring to bear upon every patient encounter what is known rather than 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.
• Establish and 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 the Consortium for Physician Performance Improvement Data Sets.
• Create multiple disease-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health.

The data display of an EHR which is equipped to perform EPM is illustrated by the following graphic and legend:

The funding of healthcare to be transformative must abandon the "piece" payment method which was instituted in 1965 with the advent of Medicare. Capitation, with payment for quality outcomes, coordination of care and care management incentivize healthcare providers to be efficient and excellent in their care rather than just being expensive.

Finally, all three elements logically merge into a patient-centered medical-home setting. The coordination of care with a primary focus on health and secondarily on disease treatment rounds out the transformative process, which SETMA believes is the future of healthcare in America. It addresses cost, quality and coordination of care.

Quality Metrics

At the core of these principles is SETMA's belief and practice that one or two quality metrics will have little impact upon the processes and outcomes of healthcare delivery. SETMA believes that fulfilling a single or a few quality metrics does not change outcomes, but fulfilling "clusters" and "galaxies" of metrics at the point-of-care can and will change outcomes. The following illustrates the principle of a "cluster" of quality metrics. A single patient, at a single visit, for a single condition, will have eight or more quality metrics fulfilled, which WILL change the outcome of that patient's treatment.

The following illustrates a "galaxy" of quality metrics. A single patient, at a single visit, may have as many as 60 or more quality metrics fulfilled in his/her care which WILL change the quality of outcomes.

SETMA's model of care is based on these four principles and these concepts of "clusters" and "galaxies" of quality metrics.

The SETMA Model of Care

• The tracking by each provider on each patient of their performance on preventive care, screening care and quality standards for acute and chronic care. SETMA's design is such that tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the personal provider, nurse, clerk, management, etc.
• The auditing of performance on the same standards either of the entire practice, of each individual clinic, and of each provider on a population, or of a panel of patients. SETMA believes that this is the piece missing from most healthcare programs.
• The statistical analyzing of the above audit-performance in order to measure improvement by practice, by clinic or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, payer class, socio-economic groupings, education, frequency of visit, frequency of testing, etc. This allows SETMA to look for leverage points through which to improve the care we provide.
• The public reporting by provider of performance on hundreds of quality measures. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool "plans of care" and the medical-home- coordination document summarizes a patient's state of care and encourages them to ask their provider for any preventive or screening care which has not been provided. Any such services which are not completed are clearly identified for the patient. We believe this is the best way to overcome provider and patient "treatment inertia."
• The design of Quality Assessment and Performance Improvement (QAPI) Initiatives - this year SETMA's initiatives involve the elimination of all ethnic diversities of care in diabetes, hypertension and dyslipidemia. Also, we have designed a program for reducing preventable readmissions to the hospital. We have completed a COGNOS Report which allows us to analyze our hospital care carefully.

Passing the Baton

While healthcare provider performance is important for excellent care of a patient's health, there are 8,760 hours in a year.  A patient who receives an enormous amount of care in a year is in a provider's office or under the provider's direct care less than 60 hours a year.  This makes it clear that the patient is responsible for the overwhelming amount of their own care which includes compliance with formal healthcare initiatives and with lifestyle choices which support their health. 

If responsibility for a patient's healthcare is symbolized by a baton, the healthcare provider carries the baton for .68% of the time. That is less than 1% of the time. The patient carries the baton 99.32% of the time.   The coordination of the patient's care between healthcare providers is important but the coordination of the patient's care between healthcare providers and the patient is imperative. 

"Often, it is forgotten that the member of the healthcare delivery team who carries the 'baton' for the majority of the time is the patient and/or the family member who is the principal caregiver.  If the 'baton' is not effectively transferred to the patient or caregiver, then the patient's care will suffer." (James L. Holly, MD)

Firmly in the providers hand
--The baton - the care and treatment plan
Must be confidently and securely grasped by the patient,
If change is to make a difference
8,760 hours a year.

The poster illustrates:

• That the healthcare-team relationship, which exists between the patient and the healthcare provider, is key to the success of the outcome of quality healthcare.
• That the plan of care and treatment plan, the "baton," is the engine through which the knowledge and power of the healthcare team is transmitted and sustained.
• That the means of transfer of the "baton" which has been developed by the healthcare team is a coordinated effort between the provider and the patient.
• That typically the healthcare provider knows and understands the patient's healthcare plan of care and the treatment plan, but that without its transfer to the patient, the provider's knowledge is useless to the patient.
• That the imperative for the plan - the "baton" - is that it be transferred from the provider to the patient, if change in the life of the patient is going to make a difference in the patient's health.
• That this transfer requires that the patient "grasps" the "baton," i.e., that the patient accepts, receives, understands and comprehends the plan, and that the patient is equipped and empowered to carry out the plan successfully.
• That the patient knows that of the 8,760 hours in the year, he/she will be responsible for "carrying the baton," longer and better than any other member of the healthcare team.

The genius and the promise of the Patient-Centered Medical Home are symbolized by the "baton."  Its display will continually remind the provider and will inform the patient, that to be successful, the patient's care must be coordinated, which must result in coordinated care.  In 2011, as we expand the scope of SETMA's Department of Care Coordination, we know that coordination begins at the points of "transitions of care," and that the work of the healthcare team - patient and provider - is that together they evaluate, define and execute that care.

Auditing

Auditing of provider performance allows physicians and nurse practitioners to know how they are doing in the care of all of their patients. It allows them to know how they are doing in relationship to their colleagues in their clinic or organization, and also how they are performing in relationship to similar practices and providers around the country.

As a result, SETMA has designed auditing tools through the adaptation to healthcare of IBM's business intelligence software, COGNOS.  Multiple articles on SETMA's COGNOS Project can be found at www.jameslhollymd.com  under Your Life Your Health and the icon COGNOS.  Those discussions will not be repeated here but auditing is an indispensable tool for the improvement of the quality of healthcare performance and for improvement in the design of healthcare delivery.
The following are a few examples of the auditing SETMA does of provider performance. 

Analytics

Through COGNOS, SETMA is able to display outcomes trending which can show seasonal patterns of care and trending comparing one provider with another.  It is also possible to look at differences between the care of patients who are treated to goal and those who are not. Patients can be compared as to socio-economic characteristics, ethnicity, frequency of evaluation by visits and by laboratory analysis, numbers of medication, payer class, cultural, financial and other barriers to care, gender and other differences.  This analysis can suggest ways in which to modify care in order to get all patients to goal.

Using digital dashboard technology, SETMA analyzes provider and practice performance in order to find patterns which can result in improved outcomes practice wide for an entire population of patients.  We analyze patient populations by:

• Provider Panel
• Practice Panel
• Financial Class - payer
• Ethic Group
• Socio-economic groups

We are able to analyze if there are patterns to explain why one population or one patient is not to goal and others are. WE can look at:

• Frequency of visits
• Frequency of testing
• Number of medications
• Change in treatment
• Education or not
• Many other metrics

Raw data can be misleading. It can cause you to think you are doing a good job when in fact many of your patients are not receiving optimal care.  For instance the tracking of your average performance in the treatment of diabetes may obscure the fact that a large percentage of your patients are not getting the care they need.  Provider Performance at the point of service is important for the individual patient.  Provider Performance over an entire population of patients is important also.  However, until you analyze your performance data statistically, a provider will not know how well he or she is doing or how to change to improve the care they are providing.

Each of the statistical measurements which SETMA tracks, the mean, the median, the mode and the standard deviation, tells us something about our performance.  And, each measurement helps us design quality improvement initiatives for the future.  Of particular, and often, of little known importance is the standard deviation.

 From 2000 to 2010, SETMA has shown annual improvement in the mean (the average) and the median results for the treatment of diabetes. There has never been a year when we did not improve.  Yet, our standard deviations revealed that there were still significant numbers of our patients who are not being treated successfully.  Even here, however, we have improved.  From 2008 to 2009, SETMA experience a 9.3% improvement in standard deviation. Some individual SETMA providers had an improvement of over 16% in their standard deviations.  Our goal for 2011 is to have another annualized improvement in mean and in median, and also to improve our standard deviation. When our standard deviations are below 1 and as they approach .5, we can be increasingly confident that all of our patients with diabetes are being treated well.

Conclusion

SETMA's Model of Care is unique among over 300 published models of care. SETMA believes that it is uniquely designed and deployed to support Patient-Centered Medical Home at its best.