(Author's Note: SETMA has been asked to submit an article for the Connexion which is the members newsletter of the Medical Group Management Association, the largest medical group organization in the world. This is the article which is being submitted.)
Southeast Texas Medical Associates, LLP (SETMA) was founded August 1, 1995. Formed from the practices of four physicians with 21 employees, it has grown into a mid-size multi-specialty group with almost 40 providers and over 250 employees. In February, SETMA will receive the Davies Award of Excellence for the use and implementation of healthcare information technology. In 2003, SETMA was named the Microsoft Clinic of the Year "for the most innovative use of Microsoft-based products and tools in reducing costs, automating workflow and substantially advancing the healthcare practice through the best use of Microsoft-based products." Physician Practice Magazine named SETMA the Southwest Regional Clinic of the Year in 2003 and in 2004 named SETMA the runner up for national clinic of the year.
But, it was not always so. When SETMA was formed there was no uniformity in how medical records were created, filed or stored. Some dictated records, others hand wrote records. Some organized records alphabetically, others used a numeric system. On August 1, 1995, SETMA's medical-record-keeping illustrated all of the problems facing the future of healthcare in America. With the new millennium approaching, with all of the potential of 21st-Century technological care, SETMA was hamstrung by the use of mixture of a 19th Century documentation system, i.e., pencil and paper, and a 20th-Century system, i.e., dictation and transcription. Neither system was capable of supporting innovation in healthcare delivery.
By the spring of 1997, the frustrations of dictation and filing led SETMA to discuss electronic medical records (EMR). Usually, when modern men and women name an object, their mind envisions a picture of that object. With the mention of EMR, our minds were blank. We had no idea what it looked like, or how to do it.
This led the partners of SETMA to attend the 1997 MGMA meeting in Washington DC. The MGMA program was dissected and tracks were laid out; each partner had a different focus. In the evening, the partners met to discuss the day's program and what might apply to SETMA and how. One of those tracks was EMR. There were hundreds of vendors at the conference. Each one told us they had the best solution. The partners returned determined to purchase an EMR, but uncertain as to which one.
SETMA's future Chief Information Office was given the responsibility to preview EMRs and to make a recommendation. After looking at dozens, one was recommended. In March of 1998, SETMA purchased both the EMR and the Enterprise Practice Management (EPM) systems from NextGen.
That is when the "fun" began. It was soon obvious that this was going to be harder than we thought. Many of the problems we faced no longer exist as the industry and the technology have matured in the past eight years. In 1998, we had a product, but we did not yet have a solution to our record keeping. The salvation of our effort flowed from our resolution and the fact that we had selected a vendor committed to our success and which was growing and evolving itself.
SETMA chose to begin by implementing the NextGen EPM, which is a robust and extensive back-office management solution. With equipment delivery schedules and SETMA's preparation, we launched the EPM on August 1, 1998, SETMA's third anniversary. In that this was the first fully electronic practice management system the Texas state insurance clearing house had seen, the challenges were prodigious. But, we now had a system which could give us practice management data that was real and useful. Our previous legacy system could produce numbers but they were never reliable and were therefore useless. We were on our way.
Simultaneous with the launching of the EPM, SETMA was developing the EMR data base which would support the clinical documentation solution we had purchased. Again, this is no longer necessary, but in 1998, no "out of the box" solution existed. Our schedule was to launch the EMR in November, but it would be January 26, 1999 before we would see our first patient with the EMR.
That day is burned into my memory. It was the "Longest Day" in SETMA's history. It began at 3:00 AM with the inputting of data into the records of the patients to be seen that day and it ended sixteen hours later with the last patient being seen.
An analogy to our implementation strategy is the story of my Grandfather's shotgun which was double-barreled with double triggers and double hammers. As my grandfather watched my then thirteen-year-old brother preparing to shoot that gun, he said, "If you're going to load both barrels, only cock one hammer." As my brother cocked both hammers, my grandfather said, "If you're going to cock both hammers, pull the back trigger first." My brother, certain of his skill, pulled the front trigger first. Ah, the wisdom of age. As the recoil of this ancient instrument slammed against his tender, and now bruised and painful shoulder, his finger slipped off the front trigger and applied enough pressure to the back trigger to discharge the second shell. His journey was only arrested when, on his back, he hit the ground.
We had been told that the best way to implement the EMR was to limit the schedule of patients and to begin with the last patient of the day. Like my brother, we loaded both barrels. We did not decrease the schedule and we began with the first patient of the day. When we got so far behind that first Tuesday morning, we started dictating again. We finished the morning session, just as the afternoon session was to begin. Our IT Department said, "You are going to continue dictating aren't you?" We said, "No, we're going back to the EMR." We finished the afternoon session two hours late, but four days later, we saw every patient in the clinic on the EMR. At the end of our fourth day, we may have felt like my brother did as he lay on his back in pain, but on Monday, we got up and did it again. Like the mother whose painful experience of child birth is a distant memory as she holds her newborn child, any memory of the pain of those first days fades and pales in the face of the care we are now able to provide to our patients.
Two events define our success with NextGen EMR and EPM. They occurred simultaneously. The first was our realization that this task was too hard and too expensive if all we were to get out of it was the ability to document a patient encounter electronically. It was this realization which pushed us past electronic patient records to electronic patient management. We realized that we had to develop the functionality for the EMR to enhance the quality of patient care, to increase the satisfaction of patients themselves and to expand the knowledge and skills of health care providers, if it was to be "worth it." SETMA's development of disease management tools, based on Peter Senge's concepts of "dynamic complexity" and "circular causality" (see The Fifth Discipline) will be featured in a presentation at the February, 2006 HIMSS meeting in San Diego. In the spring of 1999, we made this transition to electronic patient management and the investment of time and money suddenly was "worth it."
The second event occurred in May, 1999, and it set the tone for the next six years of EMR implementation. In a moment of frustration at the new system, which at this point of development was cumbersome to use and yielded little more than an acceptable record of a patient encounter, one partner said, "We haven't even begun to crawl yet," speaking of our use of the EMR. SETMA's CEO said, "You're right, but let me ask you a question. When your oldest son first turned over in bed, did you lament to your wife, -this retarded, spastic child can't even walk, all he can do is turn over in bed,' or did you excitedly announce to your wife, -he turned over in bed!'?" He smiled and the CEO added, "If in one year, all we're doing is what we are presently doing, then I'll join you in your complaint. For now, I am going to celebrate the fact that we have started and that we are doing more than before."
That celebratory attitude has given SETMA the energy and resolve to face hard times and the vision of electronic patient management has given us direction and substance to our goal. Today, we are not what we were, and we are not yet what we shall be, but we are on a pilgrimage to excellence which will never end. We started eight years ago at MGMA; where is the end? There isn't one and that is what helps us get up day after day, excited about the prospect of the future.
Note: More information about SETMA's EMR experience can be found by viewing the links below.
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