Jessica: Dr. Holly, you were telling me about a Leaders and Innovators conference you attended two months ago. At that time, the CEO, Chairman of the Board and President of Aetna Health insurance said: “Convenience is the new word for quality.” What does that mean?

Dr. Holly: When Mark Bertollini said that, I smile because SETMA had made that connection in August, 2011.

In an article published in the Examiner, we discussed Care Coordination and Coordinated Care.

The first is the process of coordinating care and the latter is the patient’s experience and perception that their care is coordinated.

Convenience was identified as one of the elements of coordination of care.

Jessica: How does that related to the idea that “Convenience is the new word for quality?”

Dr. Holly: After qualifying as a Patient-Centered Medical Home, SETMA expanded the understanding and the performing of care coordination, but we still had questions as to whether patient convenience in and of itself is worthy of a major focus of our time and energy.

The following analysis, published in August, 2011, convinced us that our patients convenience is worthy of our time and energy. The sequence of ideas goes like this:

1. Convenience for the patient
2. Results in increased patient satisfaction, which contributes to,
3. The patient having confidence that the healthcare provider cares for the patient personally, which
4. Increases the trust that the patient has in the provider, all of which
5. Increases compliance (adherence) in the patient obtaining healthcare services recommended, which
6. Promotes cost saving in travel, time and expense of care, which
7. Results in increased safety, quality of care and cost saving for the patient.

Jessica: It seems obvious once you show the connections. Thank you, Dr. Holly

Jessica: Welcome back, Dr. Anwar, when we see you, we suspect that Dr. Holly is traveling again.

Dr Anwar: Thank you, Jessica, you’re right. He is in Washington, D.C. AGAIN, this time attending the Centers for Medicare and Medicaid Innovations Summit. This is an inaugural meeting of leaders and innovators in healthcare. It is the first of its kind and as is often the case SETMA is a part of it.

Jessica: Great, what are we going to talk about today?

Dr. Anwar: Heart disease risk! SETMA has always calculated patients’ Framingham risk scores, their cardiometiabolic risk syndrome, their bad cholesterol, LDL and their good cholesterol, HDL, and the Fredrickson Classification of their cholesterol.

We will continue to do these calculations but on January 19th, SETMA purchased a new technology: Panasonic’s CardioHealth Station, which is easy and inexpensive to use, which adds to our ability to calculate a patient’s cardiovascular risk and to SHOW them that risk immediately. This new device takes two minutes to show patients the condition of their Carotid arteries.

It is called Carotid Intima Media thickness (CIMT). It directly visualizes the artery in the neck and gives a reliable indication as to whether a patient has significant atherosclerosis – hardening of the artieries. And, it will be integrated with our EMR so that the results will automatically be placed into the EMR. This makes looking at the progression or regression of heart disease easy to track.

If he or she has thickening or plague formation, aggressive therapy can be given and in a year the test can be repeated to see if improvement has taken place.

In cases where there is severe disease, other testing can be done: health will be improved and lives will be saved.

Jessica: Wow, I would love to see my results

Dr. Anwar: When the equipment is delivered, we’ll tape a show and show you your results on TV.

Jessica: Well, I don’t know about that.

Dr Anwar: It takes two minutes; there are no needles; you don’t have to disrobe and it is incredibly accurate. The great thing is that we can look at a patient’s results over time. Can you imagine actually looking at your own arteries without having to get a needle stuck in you or paying a thousand dollars or more? This is truly a case where technology is contributing to patient:

• Health
• Safety
• Quality
• Economy

Jessica: Can’t wait to see it, Dr. Anwar and as is usual, this advance in healthcare for Southeast Texas is being brought to you by SETMA!!

Supporting Information Not for the broadcast

• CIMT stands for Carotid Intima Media Thickness and refers to the combined thickness of the inner two layers (intima and media) of the carotid artery, which lies in the neck.
• Genetics and environmental factors (including diet, exposure to pro-atherosclerotic substances such as cigarette smoke, and physical inactivity/lack of exercise) combine over time to cause inflammation of the inner layers of the artery and the formation of plaque on the inner lining of the arterial wall. The process of plaque formation is known as atherosclerosis. This thickening can be measured using ultrasound and sophisticated edge-detection software to quantify the amount of disease present. The measurement of the thickness of the intima and media layers of the common carotid artery is predictive of future events (i.e. stroke, myocardial infarction, and heart attack).
• CIMT can be measured using ultrasound technology. It is a painless, noninvasive test that can be performed easily in the physician's office. The CIMT scan is brief (potentially as short as 5 minutes), does not require the patient to disrobe, is noninvasive (no needles), and does not expose the patient to radiation. It is relatively inexpensive and provides valuable information about an individual's risk of experiencing a heart attract, stroke, or MI.
• If you are using a CardioHealth® Station, the CIMT measurement will be accurately and automatically performed by the system’s advanced software algorithms. The CIMT result and report will be available immediately following completion of the test.
• Multiple studies indicate that CIMT measurement detects the presence or absence of atherosclerotic disease and also allows for assessment of the degree of atherosclerotic burden better than other noninvasive cardiovascular tests available. It is recommended by both the American Heart Association and the American College of Cardiology.
• The carotid ultrasound scanning procedure:

1. Can help assess the risk of future cardiac and cerebrovascular events.
2. Allows earlier detection and intervention
3. Allows more accurate risk stratification in asymptomatic patients than do traditional risk factors
4. Can also provide information about the presence or absence of visualized carotid plaque

• Testing over time can shed light on the efficacy of treatment by tracking thickening (progression) or thinning (regression) of the intima media thickness. Change in plaque area and size can also be visualized.
• CIMT is more accurate in predicting disease than any other risk factor alone. CIMT measurement is an independent risk factor even in the absence of any other identifiable risk factors.
• Studies have shown a high (>90%) correlation between atherosclerotic disease found in the common carotid and disease found elsewhere in the body, such as in the coronary arteries that supply the heart muscle. There is a very high correlation between the thickness of the intima media and other risk factors. Perhaps most important is CIMT's correlation and ability to predict coronary and cerebral events.
• CIMT has been shown in large-scale, prospective studies (ARIC Study, MESA Study, others) to be an independent predictor of heart attack and stroke. Moreover, CIMT and presence/absence of carotid plaque provide the most incremental predictive value over traditional risk factors alone.

1. The CardioHealth® Station is the only FDA-cleared, automated, real time system for measurement of CIMT.
2. You can manage your own testing schedule. No need to schedule all CIMT studies on a certain date.
3. You or your medical staff can be trained to measure CIMT. No need to employ and train a sonographer.
4. Extensive training and clinical resources are available.

Jessica: Dr. Holly, it looks like you got into a fist fight. What happened?

Dr. Holly: I had a little eye surgery but I am fine. What I would really like to discuss is Pre-Diabetes.

Jessica: And what is that?

Dr. Holly: It is the condition which many people have for years before they develop full blown diabetes.

Jessica: How can you know if you have it?

Dr. Holly: A simple screening test can tell you. At SETMA we routinely do screening for diabetes prevention. A test which we use to gauge the care patients with diabetes are receiving also tells us who is at risk for developing diabetes. That test is Hemoglobin A1C. If you have pre-diabetes, your HbA1c will be between 6% and 6.5%. If it is above 6.5%, you have diabetes.

Jessica: What can you do if you have pre-diabetes?

Dr. Holly: There are four main conditions which moves people from pre-diabetes to diabetes. Two are unchangeable, you can’t do anything about them: genetics and age. To are changeable: Exercise and obesity.

If you are overweight and you lost 10-15 percent of your body weight it will greatly reduce your risk of moving from pre-diabetes to diabetes. If you stay active – even if you don’t job or swim – you will reduce your risk. If you mow you r lawn with a push mower. If you walk to the store. If you part a long way from the mall and walk rather. If you do your own house work and if you don’t watch much television, you decrease your risk of developing diabetes.

Remember, the best way to treat diabetes is: don’t get it.

Jessica: Thank you, Dr. Holly, I hope your eye gets better.

Jessica: Dr. Anwar, do you realize that today marks the end of the first six months of the collaboration of Fox 4 and SETMA in the Health Living segment of Southeast Texas Live?

Dr. Anwar: Yes, I do. July 7, 2011 was our first episode. As you know all 25 of the previous episodes are posted on SETMA’s website, under In-the-News, SETMA and Fox 4 Health Living videos.

Jessica: Do you remember, what that first episode was about?

Dr. Anwar: It was about SEMTA’s LESS Initiative. It was about Losing Weight, Exercise and Smoking Smoking. In 2011, SETMA completed the LESS Initiative evaluation 54,994 times. That represents 93.4% of the patients seen at SETMA in 2011.

Jessica: 54,994 patient visits. Wow! I understand that SETMA and the LESS Initiative continues to attract national attention.

Dr. Anwar: Yes, it does. We started the LESS Initiative in 2001. It originated from our design of Disease management Tools for Diabetes, Hypertension and other conditions. We realized that there are three life-style changes which we want all patients to make. We want them to lose weight, to exercise regularly and to stop smoking and or to avoid exposure to tobacco smoke. It’s simple to do this for one patient but to do it for 55,000 patient visits, it takes a system.

In the Spring of 2011, the Agency for Healthcare Research and Quality reviewed SETMA’s LESS Initiative and in June published it on their Innovation Exchange as a program worthy of all medical practices.

Today, Dr. Holly is in Washington D.C. as the eHealth Initiative’s annually meeting receiving their 2012 Innovator Award for the LESS Initiative. Their letter announcing the award stated: “On January 11, eHI will honor SETMA for demonstrating leadership and excellence in eHealth. Through the awards program, eHI is celebrating advances that have led to improvements in the management, treatment and care of individuals with cancer, diabetes or heart disease through the use of electronic tools.”

Jessica: That’s impressive, but this is not the first national recognition which SETMA has received for Innovation is it?

Dr. Anwar: No, it isn’t. They are all posted on our website at “In-the-News” and “About Us – Awards.” SETMA is committed to excellence in healthcare. The LESS is just one of many innovations we have created in order to make sure that our patients are receiving the best care possible.

Jessica: Thank you, Dr. Anwar, and, thank you SETMA for contributing to Healthy Living for all Southeast Texans.

Jessica: Happy New Year, Dr. Holly

Dr. Holly: Thank you, Jessica

Jessica: Who is Lillian Jackson?

Dr. Holly: She is one of the dearest people I have ever know. She is a patient. I have seen her for years and saw her today.

Jessica: Isn’t that a HIPPA violation to mention her name?

Dr. Holly: It would be, if I had not asked her permission. She told me this morning how much she enjoys this show and I told her we were going to talk about her.

Today, we talked about gratitude and contentment.

Story of 10 lepers

Story of my father and contentment – peculiar man

Jessica: We must never fail to be grateful for what we have or for what we have had. Thank you, Dr. Holly, those are heart warming stories.

Jessica: Happy New Year, Dr. Holly

Dr. Holly: Thank you, Jessica, and the same to you.

Jessica: I see you’re dress in your Christmas gifts! What is that you have in your hand?

Dr. Holly: Yes, my wife wants me to be “more casual, so here I am.

This is a four-piece box of Godiva Chocolate. It represents a bond between my father and me.

When my Dad died, October 9, 2005, I thought I would not survive. For 61 years 11 months and 5 days, I had only known life with him. When he died, I had no idea what life would be like without him. For a moment, I even wonder if life would be.

For my newspaper column for January 1, 2006, I wrote about my Dad. I wrote about his character and of what I knew about him and the first thing was that he was very content. There was no thing which he needed in order to be fulfilled or to be happy.

Jessica: But what does that have to do with your father?

Dr. Holly: Well, can you imagine how hard it is to buy a gift for someone who has everything he needs and does not want anything he doesn’t have? That was my Dad. So, for Christmas I started buying him a four-pound box of Godiva Chocolate. He loved it.

It is a three hour drive to his gravesite. October 15, 2005, I visited his grave site for the first time after his burial. As I drove to Ball, Louisiana from Beaumont, I thought of the Godiva. When I entered Alexandria, Louisiana, I drove around until I found a mall that sold Godiva Chocolate. I bought a box like this one and placed it one his grave.

My brother lives close by the cemetery and when he visited the grave and saw it, he told me that that was dumb. A month later, when he visited a critter had eaten the candy. Imagining that it was probably a raccoon, my brother said that he wept and realized what a connection this was with our father who loved wildlife.

Every since, when I have visited his grave, I have placed a box of chocolate on his grave maker and within a week or so, it is eaten by a critter. I was going to visit my Father’s grave on Christmas but I was ill and did not get to. This is his box of candy and I thought we’d share a piece on the set in his memory.

What does this have to do with health? Memories, positive, creative, rich memories. The tears and sadness are replaced with active memory of my father.

In the New Year, we should all begin to develop memories which will remind us what we value. Remember the song, “You and Me Against the World”? A mother and daughter are alone. At one point the mother laments in the song, “And, when one of us has to go on alone, the memories will have to be enough to carry us on.”

Jessica: Memories are part of our health and they are powerful. Thank you, Dr. Holly and Happy New Year and good memories to all.

Jessica: Merry Christmas, Dr. Holly

Dr. Holly: Merry Christmas to you, Jessica.

Jessica: As we look to a new year, and as we are well into the second decade of a new century, what do you see in the future of healthcare?

Dr. Holly: For SETMA, the new year will see the expansion of our secure web portal and our health information exchange. The web portal is a means whereby patients can get their lab information, prescription renewals, appointments and ask questions in a manner where their information will remain confidential.

The HIE – the health information exchange – is a confidential means whereby all of the healthcare providers who care for a patient have access to that patient’s health information. How many people who have been frustrated when they arrive at a specialists office only to find that he/she has no information about their care or even why they are there.

The HIE allows everyone to be up-to-date on laboratory, procedures, diagnosis and plan of care for each patient’s healthcare.

Jessica: Are these functions common across the country?

Dr. Holly: They are in their infancy, but they are spreading. SETMA already has connectivity with Baptist Hospital and will soon have connectivity with St. Elizabeth and the Regional Medical Center in Port Arthur.

You an imagine how valuable it is when SETMA’s patients go to the hospital and their visit early in the day in the cinic is accessible to the providers taking care of them in the hospital.

There was a time when the concept of “continuity-of-care” was dependent upon being seen by the same healthcare provider, but now that continuity is also based on your medical record being available at every point where you are receiving care.

One last thing, healthcare has traditionally been delivered on the basis of a snap shot or at best a silhouette, but now with electronic records, with web portals and with HIEs, healthcare is supported by a granular portrait of the health status of a patient.

Jessica: Wow, and that’s taking place right now in Southeast Texas – in Beaumont, Orange, Port Arthur!

Dr. Holly: Yes, it is.

Jessica: Welcome to the program, Dr. Anwar. As the busiest holiday season is upon us, we begin to think about celebrations, family, holiday gatherings and FOOD!

Is it possible for eating to make you hungry?

Dr. Anwar:; Eating the wrong thing can!

I had a patient come to see me who wanted to lose weight but she became ravenously hungry at 10 AM every morning. She would then “pig out” and ruin her diet plans for the day and give up.

I asked her if she ate breakfast and she said yes. I then said, “Let me tell you what you eat for breakfast.” I told her you eat sugar coated cereal which is not high in fiber and you have white bread and fruit juice.

She said, “That’s right. How did you know?”

Jessica: I want to know, too.

Dr. Anwar: It was simple. She was eating things for breakfast which quickly turn into sugar. We call those kinds of foods, “High Glycemic Index” foods. High index foods are things like mashed potatoes, sweets, fruit juices, white bread, etc. This is why it is often said, “The whiter the bread the sooner dead!”

High glycemic foods cause the blood sugar to go up rapidly and the body produces insulin to get that sugar out of the blood. Because of the rapid rise in the blood sugar due to the high glycemic foods, the insulin levels go up faster and higher than usual.

This drives the blood sugar down, often below normal and the body produces other substances which tell the body, “Hey, we need food, the blood sugar is too low,” and you get hungry.

Jessica: What’s the solution?

Dr. Anwar: Eat low glycemic foods. We first mentioned this on Health Living on October 5ths segment on the Mediterranean Diet. For most meals that’s going to be freash vegetables, whole foods and foods with fat in them but, of course good fats. It’s going to be whole fruits and not fruit juices because fiber in the fruit makes the sugar absorb slowly, lowering the insulin response.

For breakfast, it means you will have whole grain foods - fiber remember - and some fatty food - not too much - but fat slows the absorption of the other food, decreasing the insulin response.

Jessica: What happened to the patient?

Dr. Anwar: She stopped being hungry. She didn’t eat more; she change the kinds of food she ate.

On SETMA’s website, www.jameslhollymd.com there are numerous articles about glycemic index.

Jessica: Amazing, solving the problem of hunger by eating less but different foods. That’s a good tip for the holidays.

Thank you, Dr. Anwar and Merry Christmas.

Jessica: Dr. Holly, last week we talked about “getting” by “giving.” You often seem to relate health to things other than disease and prescriptions. Is that really true?

Dr. Holly: Absolutely! Many things which affect our health have little to do with biology or science and have a great deal to do with faith, feelings and emotions.

For instance, people who are grateful for what they received are healthier than people who are constantly demanding more.

People who are grateful have fewer aches and pains than bitter people who are constantly fighting for more. Once I saw a couple who had been married for over fifty years. They were fighting constantly. When I tried to intervene. I found that this had been going on for their entire marriage. As I got SETMA’s care coordination department involved in trying to get counseling help for them, I realized that the root of their problem was selfishness, ingratitude and bitterness.

Jessica: Can someone change their view on life and become a positive rather than a negative person?

Dr. Holly: Yes, they can. Gratitude is a practice and it can become a habit. Complaining and bitterness is also a practice and it often becomes a habit.

The source of gratitude is the realization that we have more than we earned and more than we deserve. The source of bitterness is the belief that we deserve more.

Generally, positive, grateful live longer and they certainly live better. Holidays provide an opportunity for us to practice our gratitude and to avoid bitterness. And, don’t forget that children mimic what they see. Bitter, angry parents will grow bitter, angry children. Joyful, grateful parents surprisingly have joyful and happy children.

Jessica: Thank you, Dr. Holly – see, I am practicing gratitude.

Dr. Holly: Like Tiny Tim, in A Christmas Carol, “God bless us, everyone.” And, while we are giving thanks, let’s remember the men who died December 7, 1941 at Pearl Harbor.

Jessica:Welcome back, Dr. Holly, I hope you had a good Thanksgiving.

Dr. Holly: I did and thank you, Jessica. I drove 14 hours in a 30 hour period to have my Mother with my children and grandchildren for Thanksgiving dinner. Our philosophy is, “You never know when the last time is the last time so we make every time a good time so that if it is the last time, it’s OK!”

Jessica: Can you say that again?

Dr. Holly: Smiling, “Yes, you never know when the last time is the last time so we make every time a good time so that if it is the last time, it’s OK!” As you get older, you begin to understand that soon an important time will be the last time so rather than lamenting that, you make sure it’s a good time.

Jessica: I like that. Dr. Holly, how can people deal with holiday depression?

Dr. Holly: That is one of the most important health issues with which we grapple. The simple answer is “great involved.” A number of years ago, I had a patient whose son died. She was elderly and became deeply depressed from grief and loneliness. She expected a medication to be prescribed and there are times when that is important but because this lady was very involved with her faith, I made a different recommendation.

I told her, “Find a young boy who does not have a grandmother or maybe even a mother. Love him, nurture him, make him your own. And, in meeting his needs, you will find that your needs are met.”

Jessica: What happened?

Dr. Holly: She returned two months later and said, “I found him!” She told a beautiful story of how she had enriched the life of a little boy and in doing so she treated her own depression.

Winston Churchill is credited with saying: "You make a living by what you get; you make a life by what you give!"

This holiday season give yourself, your time, your love, your care to others and you will remember this as the best time of your life; no matter what your circumstances.

Jessica: Getting by Giving – a great prescription for the holidays and for life.

Thank you, Dr. Holly

Jessica: Dr. Anwar, Thank you for joining us on the eve of our national day of Thanksgiving.

Dr. Anwar: I am happy to be here

Jessica: Dr. Anwar, what is the origin of our celebration of a day of Thanksgiving?

Dr. Anwar:There are three answers to that questions all of them accurate

1. The pilgrims, we are told, had a feast at the end of the harvest season when they had come to the new world. Their American Indian neighbors brought food and they ate it together as a celebration of survival.
2. On October 3, 1789, George Washington proclaimed that on November 26th the nation have a day of thanksgiving.
3. In 1863, President Abraham Lincoln proclaimed a national day of "humiliation, fasting, and prayer." Lincoln stated: "We have forgotten the gracious hand which preserved us in peace and multiplied and enriched and strengthened us, and we have vainly imagined… that all these blessings were produced by some superior wisdom and virtue of our own. Intoxicated with unbroken success, we have become too self-sufficient to feel the necessity of redeeming and preserving grace, too proud to pray to the God that made us."

Jessica:Wow, that is powerful. Are there any health benefits to Thanksgiving

Dr. Anwar: There are. Many disease are cause or worsened by bitterness and envy. The opposite of gratitude is greed.

It is amazing how many disease can be avoided by a joyful, hopeful, grateful heart. As we thank others for their kindnesses to us and particular as we thank God, our grateful heart become a health heart.

An attitude of gratitude will make you and keep you healthy.

Jessica: Thank you, Dr. Anwar. I hope you that you, your family and all of SETMA have a Happy Thanksgiving. We are all thankful for SETMA.

Jessica: Dr. Leifeste – why is high blood pressure such a serious health problem?

Dr. Leifeste: High blood pressure (hypertension) affects almost every system in the human body – heart, blood vessels, kidneys, eyes, etc.

Jessica: What is a normal blood pressure and I have been told that if you are fifty years of age and you do not have high blood pressure then you don’t have to worry about it the rest of your life? Is that true?

Dr. Leifeste: A normal blood pressure is 120/80 and the lower your blood pressure without you have symptoms of dizziness or fainting, the better.

Actually, if you are 50 years of age and you do not have high blood pressure, your life time risk of developing high blood pressure is 90%! In other words, if you are actively doing something to avoid it, EVERYHONE will develop high blood pressure.

Jessica: What can a person do to avoid developing high blood pressure?

Dr. Leifeste: First is exercise. Nothing is as good for your heart and your blood vessels than 30-45 minutes of vigorous exercise – walking, jogging, swimming, bicycling – four or five days a week.

If you add some strength training to the aerobic exercise, -- slight weight lifting which maintains your muscle tone and muscle mass, it will help you avoid high blood pressure.

The second most important thing is don’t get fat and if you are overweight, lose 20 pounds. You don’t have to be at your ideal body weight in order to avoid high blood pressure.

Finally, stop smoking – there is nothing more destructive to your body than smoking.

Jessica: Well, we have our work cut out for us – it seems that we have heard this from SETMA before – it went like -- Loss Weight, Exercise, Stop Smoking. Isn’t that SETMA’s Less Initiative?

Dr. Leifeste: Yes. it is. LESS illness, LESS heart attacks, Less high blood pressure.

Jessica: Thank you, Dr. Leifeste

Jessica: Dr. Leifeste welcome to Fox 4 Health Living Alive at Five.

Dr. Leifeste:Thank you Jessica. I am please to be here

Jessica:Dr. Leifeste, what is the worst thing that a person with diabetes do as far as habits are concerned:

Dr. Leifete: There are three things actually: gain weight, don’t exercise and smoke tobacco.

Today, we want to focus on smoking. Patients with diabetes who smoke increase their cardiovascular disease risk by multiple times.

Jessica: What does SETMA do in order to addressing smoking by pateients who have diabetes?

Dr. Leifeste Recently, we did an audit of our records and found the following:

1. SETMA treats over 7,800 patients with diabetes
2. 714 of those show that they use tobacco (one step will be to make sure that those denotations are correct)
3. 93 of the 714 have not had a discussion about smoking cessation recorded in their chart by one of three methods: SETMA’s LESS Initiative – the SS stands for Stop Smoking; a Plan of Care which addresses smoking cessation; prescription of a medication for smoking cessation.
4. 46 of the 93 were seen by SETMA specialists who were seeing patients who are not seen by SETMA primary care.

The good news is that 99.4% of the patients SETMA’s has seen over the past three years who have diabetes have had smoking cessation addressed. 0.6% were not.

The bad news is that 9.1% of the patients with diabetes who have been seen in the past three years by SETMA continue to smoke. Our goal for 2012 is that reduce that below 4%.

Jessica: What does SETMA have planned to address this issue.

Dr. Leifeste:

We have written a letter to all 724 patients.
We are placing a telephone call to all 724 patients.
We are scheduling visits with all 724 patients to address the heart risk.

Jessica: It sounds like a good plan, let us know the results

Dr. Holly gets tested for HIV

Jessica

Thank you, Dr. Anwar, for being with us today. I understand that you don’t agree with the old adage, “What you don’t know can’t hurt you.”

Dr Anwar

I’m glad to be here again, Jessica. That’s exactly right. Several years ago, I wrote an article entitled, “The Silent Killer.” It was about high blood pressure. High blood pressure doesn’t hurt, and if you aren’t checked, you will not know you have it until you have a stroke or worse.

Jessica

Are there other conditions where there are no symptoms until it’s almost too late?

Dr Anwar

Absolutely. One of those is HIV. Until a person gets an AIDs related infection or tumor, a person will not know that they are HIV positive unless they are tested. The CDC and the Texas Department of State Health Services are promoting a state-wide HIV Screening program in health care settings.

While not participating in that program, SETMA is now offering all of our patients between the ages of 13 and 64 the opportunity to be screened for HIV, unless they decline. It is possible to live successfully and to be HIV Positive but only if you know that you are positive and receive proper treatment.

Jessica

How long have you been doing this Screening and what have the results been?

Dr. Anwar

We started in July 2011 and so far we have found two people who are not sick but who are HIV positive and did not know it. They are now receiving proper care.

Jessica

Do many people refuse to be tested?

Dr. Anwar

Unfortunately, there have been many. Often, they refuse because they are concerned as to whether their insurance will pay for the testing. This week, SETMA is sending a letter to everyone refused to be screened. In part it states:

I “If you did decline to be tested, let me encourage you to reconsider.

“If your insurance company does not pay for the HIV Screening – most do – SETMA will absorb the charges. We will pay for your testing. That’s how much we care about you. If there is a co-pay for the testing, we will waive the fee. You will pay nothing out of pocket for being screened for HIV.

“SETMA’s motto is, Healthcare Where Your Health is the Only Care. Please call your healthcare provider and tell him/her you have changed your mind and that you want to be screened for HIV.

“Please call today. Together we can all live healthily and successfully.”

Jessica

Thank you, Dr. Anwar. Once again, we find out why Southeast Texas is fortunate to have SETMA In our midst.

Jessica

Dr. Holly, as we approach the holidays, everyone is aware of how easy it is to overeat and to gain weight. I have heard about low calorie, low carbohydrate, low fat, low everything.

If you had to advise people, what diet would you recommend?

Dr. Holly

Assuming a person has no chronic illnesses, the answer is simple.  However, if they have high blood pressure, diabetes, kidney disease, heart disease, etc., it can get a little more complicated.

In general, the best diet is the Mediterranean diet.

The Mediterranean diet emphasizes:

• Getting plenty of exercise
• Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
• Replacing butter with healthy fats such as olive oil and canola oil
• Using herbs and spices instead of salt to flavor foods
• Limiting red meat to no more than a few times a month
• Eating fish and poultry at least twice a week
• Drinking red wine in moderation (optional)
• The diet also recognizes the importance of enjoying meals with family and friends.

Jessica

Why are these foods healthier than other diets?

Dr. Holly

These foods are:

Rich in antixoidants – the normal bodily functions produce chemicals call “free radicals” which are harmful to our bodies.  Antioxidants inactivate the “free radicals” and make them harmless to your body.  Foods rich in antixoidants:

Dark colored vegetables
Bell peppers
Spinach
Brocholli
Berries

But the most antixoidants are found in Dark Chocolate  The only problem is that it is high in calories.

The Mediterranean diet has a Low Glycemic levels

Jessica

What does that mean?

Dr. Holly

It means that the foods are slow to turn into sugar and thus they do not trigger rapid insulin responses. 

Elevated insulin is toxic to your body and causes many changes which we will discuss in future programs.

Jessica:

Dr. Holly, on Thursday, SETMA is sponsoring a special opportunity for healthcare providers in Southeast Texas.  Tell us about that..

Dr. Holly

Jessica, tomorrow, Dr. John Goodson will be presenting a series of lectures at SETMA.  This is during SETMA’s monthly Continuing Professional Development series, where we close our practice for half a day.  For 3-4 hours all of the healthcare providers at SETMA meet for peer review, quality review and for discussions of how we can improve the care we give our patients. 

At 12:30 PM Thursday, all healthcare providers in Southeast Texas are invited to the Holidome on Walden road to hear Dr. Goodson’s lecture entitled, “The Promise of Primary Care.”  Actually, anyone from the public is also welcome.

Jessica

Who is Dr. Goodson?

Dr. Holly

Dr. Goodson is a practicing internist.  He is an Associative Professor at Harvard University School of Medicine and also teaches in the residency programs at the Massachusetts General Hospital, which recently celebrated its 200th University.

He founded an organization called The Promise of Primary Care and dedicates a significant part of his time promoting Primary Care.  His website can be seen at:  http://thepromiseofprimarycare.org/

There are three sections to the website:

• Practice Innovations
• Primary Care Advocacy
• Expanding Primary Care

There are articles written by SETMA in each of these sections.

Dr. Goodson says the following about himself:

“My core work is primary care.  I see 70 or so patients per week in my practice, work with an office nurse and medical assistant (my “teamlet”) and collaborate with a talented and experienced adult nurse practitioner.  I admit, round on and arrange for the discharge follow-up and home care on all my patients.  I rotate call with my physician team members.

“I am a medical educator for residents and practicing physicians, working as a preceptor, attending and as a course director and speaker.

“As an activist, I have supported universal health care access.  In my professional societies, I have participated in national efforts to improve primary care compensation relative to specialists.”

Jessica

The public meeting at the Holidome on Walden Road at 12:30 PM on Thursday, right? 

Would it be OK if we had a Fox 4 team interview Dr. Goodson?

Dr. Holly

That would be great. 

Jessica

Thank you, Dr. Holly.  We’ll look forward to hearing more about the Promise of Primary Care

Jessica

Welcome back to Fox 4 Southeast Texas Healthy Living, Dr. Anwar.  Last week, we were discussing SETMA’s I-Care Initiative.  Can you tell us some of the special problems which our elderly experience in nursing homes?

Dr. Anwar

Thank you, Jessica.  SETMA’s I-Care’s team’s commitment is stated on our website and in part declares:

“SETMA's I-CARE for the elderly is founded on our commitment to the sanctity of human life and to the proposition that everyone deserves to preserve their personal dignity. SETMA's treatment of Nursing Home residents is grounded in our electronic patient management with nationally acclaimed treatment tools for the special needs of elderly patients who require residential care.”

This is the philosophy in part.  The reality is that patients are often unable to care for themselves, unable to move about, unable to feed themselves and sometimes are unable to talk or to responded to questions appropriately.

One of the great strengths of I-Care is that we use the same medical record in the nursing home which is used in the clinic, in the emergency department, in the hospital, in fact, at very point of care.  The electronic medical record SETMA uses makes it possible for us to know exactly what is going on with patiens at any particular time.

SETMA has designed special tools to evaluate, document and treat the five major problems faced by nursing home patients. They are:

• Hydration
• Nutrition
• Fall Risk
• Skin Care
• Depression

Jessica

Dr. Anwar, we hear a lot about medication errors in healthcare today.  How do you deal with this very complex issue in the nursing home?

Dr. Anwar

The continuity of care between different facilities and different providers is critical to excellent care and the need is no where greater than in the Nursing Home.
The EMR makes this much easier because I have the same record in my office that the nursing home has in their facility.  Our staff continually updates the electronic record so that the laboratory results, the medications, the plan of care and the treatment plan which are seen by the nursing home staff in Silsbee or Port Arthur is the same that the I-Care team sees in our offices.

Jessica

Is this integration and continuity of care common in Nursing Homes?

Dr. Anwar

It is in Southeast Texas and SETMA is working regionally and nationally to encourage this kind of care for every person who is treated in a nursing home.

Jessica

Thank you Dr. Anwar, and if you or your loved one needs care in a nursing home, you ought to call Dr. Anwar and SETMA’s I-Care team.

Jessica

Dr. Imtiaz Anwar is a board-certified Internal Medicine specialist at SETMA.  He is a partner and leads SETMA’s I-Care project.  Thank you for being with us today, Dr. Anwar.  Can you tell our audience what I-Care is?

Dr. Anwar

Thank you, Jessica, I am pleased to be here.  I-Care is a new generation of a program which my former partner, Dr. Mark Wilson, started over 30 years ago.  I-Care is our program for providing excellent and compassionate care for residents in long-term care facilities in Southeast Texas.  Commonly, these facilities are called Nursing Homes.

At SETMA, we have a pro-life commitment toward everyone but particularly the unborn , the disabled and the elderly.  SETMA’s I-Care Team is made up of several dozen staff including nurses, phlebotomists, nurse practitioners, physicians and administrators. 

On SETMA’s website at www.jameslhollymd.com I-Care’s mission statement is posted, which states:

“To provide long-term, residential healthcare, addressing our patients’ unique needs, while preserving their dignity, self-respect and quality of life.”

Jessica

Dr. Anwar, why is this part of healthcare so important to you and to SETMA?

Dr. Anwar

I was born in Pakistan but have become a Unites States citizen.  The home of my birth and now of my choice have many things in common.  One of them is our love and respect for our parents and for the elderly in our communities.

To SETMA, I-Care is an extension of that love and respect.  I-Care has three objectives; our love for and respect of the elderly defines the first objective  which is:

“To offer compassionate, comprehensive care in order to enhance to the fullest the functional capacities and quality of life of the long-term care facility patients whom we serve.  In the pursuit of these objectives, we are committed to preserving the dignity and self esteem of all of our patients.”

I-Care’s other two objectives are:

“To guide and support long-term care facility residents and their families every step of the way as they face transitions, adjustments and challenges in their lives. Readily accessible as providers, we are here 24/7/365 days a year to bring the best medical care and standards to our patients.

“To utilize comprehensive cutting edge electronic medical records, treatment guidelines, electronic patient management tools and medical equipment that ensures timely receipt of diagnostic laboratory and procedure results, and medical correspondence..”

Jessica

Thank you, Dr. Anwar.  You will be with us again next week, would you be willing to continue this introduction to I-Care and to discuss some of the problems patients have in Nursing Homes?

Dr. Anwar

I will

Jessica

Thank you.

Thank you, Dr. Anwar.

Jessica

After your one-word answer to my question last week, it made me think of Gary Cooper.  After answering, “Yep” and “Nope” to several questions, he was asked, “Can you say anything but “Nope,” and he said, “Yep.”

On SETMA’s website, you have the results of a study which was released last week.  It is called “Medical Home Feedback Report.”  Can you tell us about what that report means and what we can learn from it?

Dr. Holly

“Yep”

The full results of the study can be found HERE

• The Centers for Medicare & Medicaid Services (CMS),  contracted with RTI International, a nonprofit research organization,
• to analyze patterns of care, health outcomes, and costs of care for  Medicare fee-for-service (FFS) beneficiaries receiving healthcare services from clinical practices that are National Committee for Quality Assurance (NCQA)-recognized medical homes.
• In particular, CMS wanted to know if there are particular attributes of medical homes that are more favorably related to better outcomes of care.

The study compared each of 312 practices with a benchmark which was determined by statistical analysis and with the average performance of the 312 Medical Home.  It focused on:

• Quality of Care – LDL, HbA1C and Influenza Immunization
• Coordination of Care and continuity of care
• Annual Payments
• Physician Payments by type of service
• Potentially Avoidable Payments based on Ambulatory Care Sensitive Conditions

Jessica

Can you tell us about SETMA’s results?

Dr. Holly

On the quality metrics we out performed both the benchmarks and the other 311 Medical Homes

With the other categories, we out performed the benchmarks in every category and were equal to or better than the average of the other Medical Home practices.

In the measure over time, SETMA shows significant improvement each year.

Jessica

What will SETMA do with this information?

Dr. Holly

This is the first time that anyone has this kind of information at the practice level.  We have already started to think about how we can improve our outcomes and control the cost of care while maintaining its quality.  We have asked CMS and RTI to give us this same review every three months. 

Jessica

That’s impressive.  We’ll look forward to hearing more in the future.

Jessica

Dr. Holly, is it possible to identify one thing which by itself is the most important thing a person can do for themselves which would result in Healthy Living?

Dr. Holly

Yes

Jessica smiling

Will you tell our audience what that one thing is?

Dr. Holly also smiling

Of course, I just want to be a good guest and answer the question you asked.  The single most valuable thing anyone can do for their health is to be active.

That doesn’t just mean exercise.   Listen to the following NY Times summary in 2010 of a study from the Journal, Medicine and Science in Sports and Exercise:

“Men who spent more than 23 hours a week watching TV and sitting in their cars (as passengers or as drivers) had a 64 percent greater chance of dying from heart disease than those who sat for 11 hours a week or less.

What was unexpected was that many of the men who sat long hours and developed heart problems also exercised. Quite a few of them said they did so regularly and led active lifestyles. The men worked out, then sat in cars and in front of televisions for hours, and their risk of heart disease soared, despite the exercise. Their workouts did not counteract the ill effects of sitting.”  

(May, 2010, Medicine and Science in Sports and Exercise)

Jessica

So that means it is OK to watch Southeast Texas Live?

Dr. Holly smiling

Of course but then go out an plow the garden!  My father was a good example of being active as opposed to exercising.  I think I never saw him ever exercising and he smoke heavily all of his life, but he was busy all of the time.  He chose a job which kept him outside and active.  He came home from work and went to the garden or to the barn or….  He never sat around.

The Amish don’t exercise but the average Amish man walks 18,000 steps a day and one walked 57,000 steps in one day while plowing.

Jessica

So, we need to keep moving – walking, mowing, sweeping, swimming – staying active.

Dr. Holly

It is the most important thing you can do. EVERY disease known  to man is either caused by or worsened by inactivity.  The couch potato is an unhealthy life style.

Jessica

Dr. Holly, what is the SETMA Model of Care?

Dr. Holly

In general, a model of care defines the method, content of focus of a healthcare organization.  There are about 300 distinctive Models of Care described in the medical literature.

The SETMA Model of Care is new and it involves five steps:

1. The tracking of over 200 quality metrics on every patient we see.    A quality metric is a standard of care which has been endorsed by an agency which does the research and vetting of excellence in healthcare.
2. The auditing of provider performance on a group of patients, usually the provider’s entire panel of patients.
3. The analyzing by statistical methods of the outcomes of care by each provider and by the practice.    For instance, knowing the standard deviation of the patients you treat with diabetes allows you to focus your efforts to improve the care of all patients with diabetes.  SETMA’s standard deviation of patients with diabetes has improved dramatically over the past ten years.
4. The public reporting by provider name of the provider’s performance on the quality metrics we track.
5. The designing of quality of care improvement initiatives based on the first four steps.

Jessica

Dr. Holly, how does that help an individual patient.

Dr. Holly

It lets the patient know that there is a plan and a goal behind the care they receive.  That care is based on the best evidence available and if followed it will make a difference in their life.

Jessica

Is this kind of plan typical for medical practices across America?

Dr. Holly

It will be now and in the future.

Jessica

Wow, this sounds like Beaumont has access to leading edge healthcare right now.  Thank you, Dr. Holly.

Jessica:

Dr. Holly, in our Healthy Living segments, we have talked about the patient’s Baton, about measuring quality of care and reporting that measurement publicly on SETMA’s website and last week we talked about Medical Home.  How are all of these related?

Dr. Holly

Placing the patient at the center of care, rather than procedures, tests and operations, means that care is coordinated between providers and between points of service.

Jessica

Can you give us some examples of what coordinated care means?

Dr. Holly

Yes, for instance, when a patient leaves the hospital a number of complicated events take place.  The patient is given medications but are they the same or different from what the patient was taking before?  Are they all different are only some of them?

A major part of coordination of care is medication reconciliation.  This includes giving the patient a list of medications they should take and a list of medications they once took but should no longer take.  Those lists must be complete and legible.  Because SETMA uses electronic patient records in the hospital and in the clinic, we are able to do this.

The major of readmissions to the hospital which could have been prevented are related to inadequate coordination of medications and incomplete medication reconciliation.

Jessica

One of the problems, all patients have experienced is taking a prescription to the pharmacy and finding that the pharmacy would not read it.  How does SETMA deal with this.

Dr. Holly

We use electronic prescribing.  Almost all pharmacies now can do this.  Rather than writing out a prescription which the patient takes tot the pharmacy, with a single click of a button, SETMA sends the prescription to the pharmacy of the patient’s choice and received a notice that the prescription has been received. It is safe, convenient and it is legible.

Jessica:

There has been a great deal of discussion about something called “Medical Home.”  What is it?

Dr. Holly

The full name is Patient-Centered Medical Home.  While the entire discussion is complex, simply it is an attempt to recover the personalized medicine we all experience as children but to do so in a highly technological age.

Jessica:

Why is it called a “Home?”

Dr. Holly

A home is a place where:

• It is a place where you need fear no harm from those who are with you.
• It is a place where your needs are met.
• It is a place you can go when you don't know what else to do.
• It is a place where you can be yourself and you can tell others how you really feel without fear of rejection.
• It is a place where others really want to see you succeed.
• It is a place where if you are away too long, someone is calling to find out if you are OK.
• It is a place where you are treating like family.

In a Medical Home, you are the central focus and your needs are the only important needs.  That is why SETMA’s motto is:  Healthcare Where Your Health is the Only Care.

Jessica:

How does a medical practice become a Medical Home?

Dr Holly

It typically takes two years or more for a practice to develop the tools and processes which fulfill the requirements of being designated as a Medical Home.  SETMA started the process in February 2009 and completed it in April 2010.

Jessica:

Can a practice be accredited as a Medical Home and is SETMA accredited?

Dr. Holly

Yes, there are four agencies which evaluate practices as medical homes.  NCQA, AAAHC, the Joint Commission and URAC.  SETMA is recognized by both NCQA and AAAHC.  Over the next few years, we believe that our patients will increasingly benefit from the work we have done in this area.

Jessica:  

Dr. Holly, how can patients know how good the care thy are receiving  is?

Dr. Holly: 

In a 2007 piece on Pubic Reporting and Transparency,  The Commonwealth Fund (A Private Foundation Working Toward a High Performance Health System) stated: “ Providers. Hospitals, physicians, nursing homes, and other health care providers would benefit from more transparent price and quality information as a feedback loop for improved performance and for identifying the most efficient and effective referrals.”

In 2009, SETMA decided that with our ten year experience with quality metrics, that we were ready to begin public reporting of our performance and we decided to do it by provider name.

This is the only objective way in which to judge the quality of care you are receiving.

Jessica: 

Is this information available to the public?

Dr. Holly

Yes, it is posted on our website under the title Public Reporting.  If you want to see how I treat diabetes, you can go there, look up one of the quality metric sets on diabetes (there are seven different ones) and look up my name.

SETMA tracks over 200 quality metrics on every patient we see. 

Jessica:

What do you do with this information?

Dr. Holly

In addition to tracking those metrics one patient at a time, we audit the performance of each healthcare provider over the entire group of patients they treat.

We then analyze that performance statistically in order to understand how we can improve patient care in SETMA.

In monthly meetings, those results are reviewed for each provider and suggestions are made as to how to improve performance.

But, a good place for a patient to start is to look up their healthcare providers performance.  For SETMA, that can be done right now.

Jessica:

How many medical groups are voluntarily doing this by provider name?

Dr. Holly

We are unaware that there are others doing this.

Question:  Dr. Holly, what are the Framingham Risk Calculators and why are they important?

You have heard the terms “evidence-based medicine,”  “random controlled studies” and “double blind studies.”   These are the methods and the results of scientific investigation to determine the cause of disease and the best way to prevent, cure  or control a disease.

One of the earliest and now the longest running scientific study is the Framingham Heart Study.  Started in 1949 in Framingham, Massachusetts, the study now includes three generations of the same family members and has established the causes, cure and control of heart disease.

Question:  Dr. Holly, how can this help people in Southeast Texas?

The Framingham Heart Study has developed twelve risk calculators which can let you know what your is for heart disease, stroke and other heart-related illnesses. The higher your risk, the more important it is for you to take steps to avoid heart disease.

The American Academy of Family Practice recommends that every five years a family physician should calculate one of the Framingham Risk Scores for each of their patients.

At SETMA, we calculate all twelve risk calculators every time your are seen, and because we use electronic health records, it takes us one second to do it.

Question:  Dr. Holly, in a practical sense, how does this really help a patient?

One of the questions healthcare providers have to answer for their patients is “If I make a change in my life, will it make a difference in my health?”   In reality, we ask people to make changes now which will benefit them twenty or thirty years from now.

In order to do this, SETMA has designed a “What If Scenario” with the Framingham studies.  It works like this, if you are 50 years old, your actual heart age is 50.  One of the Framingham Scores will calculate, based on a number of factors your relative heart age, which may be 70. 

In that case, we re-calculate for you what your relative heart age will be if you improve your blood pressure, cholesterol, and stop smoking.  We can show you that your relative heart age may go down to 55 thus we can prove that “if you make a change, it will make a difference.”

“The Baton” is a pictorial representation of the patient’s “plan of care and the treatment plan,” which is the instrument through which responsibility for a patient’s health care is transferred to the patient.  Framed copies hang in the waiting room of SETMA II and will soon hang in all public places throughout SETMA’s clinics.  A poster copy will be hung in every examination room.   The poster declares:

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.

Hemoglobin A1c (HbA1c)

1. The HbA1c  (spoken as hemoglobin A1c) is a blood test which tells us what the average blood sugar has been for the past three months.  If your HbA1c is above 6.5%, you have diabetes.  If your have diabetes and your HbA1c is below 7.0%, you are receiving excellent care for your diabetes.
2. Every study for quality of care and for complications from diabetes is based on HbA1c
3. On our website, SEMTA publicly reports, by provider name, performance on over 250 quality metrics.  If you want to know how a SETMA provider performs, go to Public Reporting. 
4. Every patient with diabetes, should ask their healthcare provider the following questions:
   
   
   1. What is the provider’s mean HbA1c – that is what is the average HbA1c for all of the provider’s patients with diabetes?
   2. What is the provider’s standard deviation of HbA1c – this tells you how well the group is being treated as a whole?   The key to understanding a standard deviation is that it should be improving  and the ideal is 1.0 or below.
   3. The most critical question is, are the mean and the standard deviation improving?


5. SETMA’s mean HbA1c is 6.65% which is excellent.  It has improved every years since 2000.
6. SETMA’s standard deviation for HbA1c is 1.2.  It has improved every year since 2000 going from 1.98 in 2000 to 1.2 today.  Not where we want it but improving.
7. As a Joslin Diabetes affiliate SETMA is both committed to and held to the highest standards of care for patients with diabetes.