Formed August 1, 1995, Southeast Texas Medical Associates, LLP (SETMA) recognized that excellence in 21st-Century healthcare was not possible with 19th-Century medical-record methods, i.e., pencil and paper, or with 20th-Century methods, i.e., dictation and transcription.  Therefore, eighteen years ago, SETMA began the process of adopting an electronic medical record (EMR).  In October, 1997, SETMA examined over fifty EMRs.  On March 30, 1998, writing a $650,000 check, SETMA purchased the EMR which we currently use.  Eighteen years ago many thought that was a mistake, as in those early days healthcare providers had to develop the content of the EMR themselves.  We had bought an empty box.  Therefore, it was Tuesday, January 26, 1999 before we began using the EMR to document patient encounters, but by Friday, January 29, 1999, all patient visits were documented in the EMR.

In 1996, SETMA also believed that 21st Century healthcare was going to be driven by quality performance and SETMA rejected the old model of care where the healthcare provider was the constable imposing health upon a passive recipient, the patient.  Therefore, SETMA developed a model of care where the patient is an active member of his/her healthcare team and where the healthcare provider is like a consultant, a colleague, a collaborator to facilitate healthy living, with safe, individualized and personalized care for each patient.  SETMA’s model is driven by the fact that we serve a population which had received disjointed, unorganized, episodic care, focused upon things done to, or for patients who have limited resources with which to support their health care goals.

Four Seminal Events - May, 1999 will always be critical

Without doubt, in 1995, the first step in forming what is now SETMA was the adoption of a team approach to patient care.   (see http://jameslhollymd.com/About-SETMA/pdfs/the-setma-team-and-the-setma-culture.pdf) That team focus will be the central part of the story when the history of SETMA is written.  The second critical decision was the EMR.  But, in SETMA’s history May, 1999 will always be central.   In the first week of May, 1999, only 100 days after SETMA first used the EMR, four seminal events took place.  These events defined and directed SETMA’s future.

The first event took place the first week of May, 1999, when SETMA’s CEO announced that the EHR was too hard and too expensive if all we gained was the ability to document a patient encounter electronically.  When we began, it took a provider five minutes to create a chart note.  Our CEO concluded EHR was only “worth it,” if we leveraged electronics to improve care for each patient; to eliminate errors which were dangerous to the health of our patients; and, if we could develop electronic functionalities for improving the health and the care of our patients and of population groups.  This was our transition from EMR to electronic patient management (EPM).

We also recognized that healthcare costs were out of control and that EPM could help decrease that cost while improving care.  Therefore, we began designing disease-management and population-health tools, which included “follow-up documents,” allowing SETMA providers to summarize patients’ healthcare goals with personalized steps of action through which to meet those goals.  We transformed our vision from how many x-rays and lab tests were done and how many patients were seen, to measurable standards of excellence of care and to actions for the reducing of the cost of care.  We learned that excellence and expensive are not synonyms.  In ten years, these steps would lead us to begin public reporting by provider name on over three hundred quality metrics (http://jameslhollymd.com/public-reporting/public-reports-by-type).

The second event was that from Peter Senge’s The Fifth Discipline, we defined 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:

1. Pursue Electronic Patient Management rather than Electronic Patient Records
2. Bring to every patient encounter what is known, not what a particular provider knows
3. Make it easier to do “it” right than not to do it at all
4. Continually challenge providers to improve their performance
5. Infuse new knowledge and decision-making tools throughout an organization instantly
6. Promote continuity of care with patient education, information and plans of care
7. Enlist patients as partners and collaborators in their own health improvement
8. Evaluate the care of patients and populations of patients longitudinally
9. Audit provider performance based on endorsed quality measurement sets
10. Integrate electronic tools in an intuitive fashion giving patients the benefit of expert knowledge about specific conditions

In 2009, we would discover that these principles are essentially the principles of PC-MH and that the past ten years had prepared SETMA to formally become a PC-MH.  Between 2009 and 2014, SETMA became accredited as a medical home by NCQA, AAAHC, URAC and The Joint Commission and in doing this, SETMA became the only practice in America to do so.

Cortez - Fahrenheit 451 - Maginot Line

The third seminal event was the preparation of a philosophical base for our future;  written in May, 1999 and published in booklet form in October, 1999, this blueprint was entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine With Electronic Health Records which Evolves into Electronic Patient Management”.    This booklet was distributed to our practice and our community. It became our declaration that we were going to succeed at this process at any cost and at any effort.  Like Cortez, who scuttled his ships on his expedition to Mexico so that there was no turning back, this booklet was SETMA’s public declaration that there was no going back.  We were going to succeed.    Our charge to ourselves was and our counsel to others is, “Don't give up!”  The key to success is the willingness to fail successfully. Every story of success is filled with times of failure but every story is also characterized by the relentlessness of starting over again and again and again until you master the task.  When we started our IT project, we told people about what we were doing.  We called that our "Cortez Project".  Like Cortez, we scuttled our ships; there was no going back.  We had to succeed.

There were other “named” initiatives in SETMA’s history in addition to the Cortez declaration.  There was the Fahrenheit 451 Initiative (the kindling point of paper) where we recognized and declared that paper was too expensive and too hard for record keeping and for transformation of healthcare.  While we did not burn books, we set our sights on getting rid of paper in our practice.

 There was also the Maginot Line Initiative.  Like the fixed fortifications built by the French after World War I,  as an obstacle to invasion by Germany and which were fortifications were  defeated by the ability of mechanized war-machines to “go around the line,” when confronted by a seemingly insurmountable obstacle to our successful transformation, SETMA went around the obstacles. 1

As we began defining and developing critical supports required for success in Performance Improvement, we found them to be:

1. Care where the same data base is being used at ALL points of care.
2. A robust EHR to accomplish the above.
3. A robust business-intelligence analytics system, which allows for real-time data analysis at the point of care.
4. 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.
5. Quality metric tracking, auditing and statistical analysis.
6. Public Reporting of quality metric performance by provider name.
7. Quality Improvement initiatives based on tracking, auditing and analysis of metrics.
8. 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.
9. 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.
10. Monthly peer-review sessions with all providers, to review provider performance and to provide education in the use of electronic tools.
11. Adequate financial support for the infrastructure of transformation.
12. Respect of the personal value of others and the caring for people as individuals.
13. 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.
14. 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.

These four seminal events have defined SETMA’s pilgrimage and they remain the foundation of our success.  They have not only defined our past but continue to determine our future.