Eighteen years!  As SETMA celebrates this anniversary, we also welcome the first senior medical student to participate in a Patient-Centered Medical Home (PC-MH) Externship at SETMA.   From the University of Texas Health Science Center at San Antonio School of Medicine, she started on July 29, 2013 and we expect to Family Medicine Chief Residents from Texas A&M College of Medicine to join us in August for a rotation. 

Nothing could be more satisfying in SETMA’s history and advancement than to be entrusted with introducing senior medical students and primary-care residents to the practical applications of best practices, evidence-based medicine, informatics, analytics, and PC-MH.  In preparation,  SETMA has created a two-volume syllabus for what is formally title” MS$ (Medical Student 4th Year) PC-MH Selective”.  The syllabus will evolve and our understanding of how we can improve students’ experience at SETMA will grow; but, our commitment to excellence in healthcare and our belief in our responsibility to contribute to the training of the next generation of nurse practitioners, physician assistants, physicians and other healthcare colleagues will remain constant.  By the time this article is published, we expect to have an electronic copy of the syllabus on our website at www.jameslhollymd.com. 

The Externship course objectives are to identify, describe, define and to experience:

• The critical role of primary care in healthcare transformation.
• Why the future of healthcare is dependent upon primary care.
• Why the only segment of medicine which can effect sustainable change is primary care.
• Why the best and the brightest will find the greatest fulfillment in primary care.
• How patient-centered medical home is the hub and the core of healthcare transformation.
• Show students how excellence in care and practice financial stability are not mutually exclusive.

The syllabus begins with SETMA’s Mission Statement, which is our promise to Southeast Texas; it states:

“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 in by example.” 

The origin of this mission statement is worth noting.  In October of 1997, two of the co-founding partners of SETMA attended the Medical Group Management Association’s (MGMA) annual meeting in Washington, D.C.  Drs. Mark Wilson and James L. Holly also attended a one- day, pre-conference on “strategic planning.”  As the two left one session, Dr. Wilson, addressing Dr. Holly, commented, “You know, Larry, our goals may not be the same.” 

SETMA had only been founded two years and two months before and while we were gratified by how much we had accomplished, as evidenced by the dialogue which had taken place in this pre-conference, we were still feeling our way along in personal relationships and team building.

In response to his comment Dr. Holly said to Dr. Wilson, “Mark, you may be right; what is your goal?”   After Dr. Wilson stated his goals, Dr. Holly opened his notebook and showed him a statement outlined in bold ink.  The statement incredibly was word for word what Dr. Wilson had said.  At that moment, we knew that our mission was clear and that the future of SETMA was secure.  SETMA has never deviated from this mission statement’s spirit and intent.

The outline of the entire syllabus is too long to print here but the following example from SECTION II, entitled, “Electronic Medical Records (EMR) -- Electronic Patient Management,” gives a sense of its content and direction.

Part 1.  More Than a Transcription Service: Reorganizing the Practice of Medicine with Computerized Patient Records (CPR)

This extensive document was prepared by SETMA in 1999 and was published in booklet.  It allowed our patients to know where we were headed with electronic patient records and in retrospect it laid the foundation for SETMA becoming a patient-centered medical home before we had ever heard the term.  Many and most of the element of PC-MH are contained in this manuscript.  Its review will help the student see how effective and excellent future advances and transformation will logically and necessarily be built upon past work and accomplishments.

Part 2.  Systems Thinking in the design of EMR Tools 

SETMA cannot be understood without knowing the impact that Dr. Peter Senge’s The Fifth Discipline had upon SETMA’s development, upon the design of our Model of Care and upon the deployment of our EMR.  Electronic medical records (EMR) provides the means for the required  “shift of mind,”  but does not necessarily dictate that such a shift will take place. Often, EMR is only used as a glorified transcription tool whereby a patient encounter is documented electronically, without providing significant advantages in processing of information, and without the patient’s care profiting from sound science. 

Change is not easy. It often creates anxiety and insecurity, even, and maybe especially, among healthcare providers. However, to create excellence in healthcare,  providers must continually be "learning" which will require a change in the understanding of the nature of learning and will also require the elimination of barriers to learning. The externship will help the student, at whatever level of training, understand the sustainability of excellence through morphing from the pursuit of EMR to the pursuit of electronic patient management.

Part 3.  Electronic Patient Management

This document was prepared in 2006 and is entitled Beyond Electronic Medical Records: the Hope and Promise of Electronic Patient Management.  Transitioning from an EMR mentality to an Electronic Patient Management (EPM) goal is to apply Dr. Senge's concept of "generative learning" to the field of medicine. Addressing the concept of a "learning organization," Senge said: "This then is the basic meaning of a learning organization€¦ continually expanding its capacity to create its future. For such an organization, it is not enough merely to survive. ‘Survival learning’ or what is more often termed ‘adaptive learning’ is important €“ indeed it is necessary. But for a learning organization, ‘adaptive learning’ must be joined by ‘generative learning,’ learning that enhances our capacity to create."

Part 4.  Chronic Problem List Reconciliation

This part of the syllabus is intended to introduce the student to the necessity for ongoing development of the tools and innovations surrounding “systems thinking” in healthcare and particularly in healthcare informatics.  Perhaps the two most difficult aspects of healthcare is the maintenance of accurate, up-to-date and complete medication lists and chronic problem lists.  As an illustration to the systems approach to problem solving, this work will be reviewed with the student to show how imperative it is that the power of electronics is used to solve complex problems and to make it “easier to do a critical task well than not to do it at all.”

Memories

It is not possible to experience an anniversary without thinking about those who are no longer with SETMA.  It was August, 2007, when Dr. Wilson learned of his illness and left his active participation with us.  I could only wish that he could see us now. The foundations of much that was laid in our first twelve years have come to fruition in the last six years. 

It was March of 1998, when SETMA signed a bank note for $650,000 to purchase the electronic medical records which have formed the principle part of that foundation.  A good friend and consultant physician said to me at that time, “What a waste of money and without any benefit to patients.”   Our accountant told us we had lost our minds and that we would never pay that debt.  Since that time, we have spent more than $8,000,000 on information technology and all of it is paid. 

There are other memories, but these two stand out.  In seven years, we will celebrate our 25th Anniversary.  I wonder where we’ll be then?