Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Transforming Your Practice - Medical Records
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    May, 1999 -- When I was a child, medical records were kept on a 3x5-file card. The information essentially reflected the date and a one-word statement of what transpired in the visit to the doctor, often related merely to a shot or medicine, which was given. Patients paid a dollar for the visit, a dollar for the shot and a couple of dollars for the medication. Expectations were low and expenses were, also. The physician kept most of the important patient information in his/her head. Therefore, when the physician wasn't available, data on the patient wasn't available.  This system was extremely personal and was often very satisfying for the patient and the physician. When I was born, Dr. Culpepper was my family doctor. In 1949, my family moved and did not use Dr. Culpepper as a physician again. In 1973, when I graduated from medical school, I called Dr. Culpepper and said, "Dr. Culpepper, I wanted to say hello and tell you I have graduated from medical school." Dr. Culpepper was in his early eighties and said spontaneously, "How are Bill and Irene," calling my parents by their first names, after not having seen them in 24 years. Dr. Culpepper had a wonderful mind, but it could only be in one place at a time. For a PDF copy of this article, see:  Revolutionizing the Practice of Medicine And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management .

    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

    January, 2007 -- It is possible for healthcare providers to be overwhelmed by the volume of valuable information available for medical decision making. The organization and storage of that information is particularly ill suited for easy access and application in clinical settings. Electronic patient records have the potential for making current and future information available for use in improving the quality of treatment out comings. Success in applying medical science and random-controlled-trials date to healthcare will be dictated by the design of EMR products and particularly by the display of data and treatment decision-making tools. In his book, The Fifth Discipline, Dr. Peter Senge identifies "systems thinking" as the solution to the management of complex data issues in business. These principles are equally applicable in medicine and particularly in the design of EMR tools for the support of healthcare decision making.  Utilizing Senge's concepts of metanoia and “circular causality”, this paper examines the implications of systems thinking for the design of EMRs and for the display of data. In addition, the issues of data sharing between specialties, disciplines and disease management is addressed.

    If all we generally talk about is Electronic Patient Records or Computerized Patient Records or Electronic Medical Records, or ...then everyone is going to get the idea that when they create the ability to produce an electronically generated document of a patient encounter, they have arrived. The problem with this is that many health care providers, who are very interested in joining the 21st-Century methodology of health care (EPM), are going to buy a product which they suddenly find is wholly inadequate for the tasks at hand.  To accomplish metanoia in medical informatics, I would immediately hold up the standard of Electronic Patient Management (EPM). I would describe it at least, if not define it. I would detail and illustrate its every aspect. I would model it where it exists, and I would dream about it where it does not.   And I would herald the truth that the ability to document a patient encounter only "gets you on to the playing field" in EPM. That ability is not the end point; and, the vendor who can only do that is not holding the winning hand.

    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.

    With the use of an EMR, SETMA has become a recognized and accredited Patient-Centered Medical Home. SETMA has built a website which represents the cutting edge of EMR use.  Thought leaders in healthcare transformation from across the nation, use SETMA’s website as a source for creative and innovative ideas about the future of healthcare.  From a personal standard point, in the 36 years I have maintained a private clinic before and including SETMA, 39% of the time I have used EMR as a means of documenting a patient encounter and as a means of improving the quality of care delivered in those clinics.  If I practice for eight more years (a total of 44 clinic years), I will have practiced 22 years or 50% of my career with an EMR.  To the next generation of healthcare providers, this observation will seen quaint but to those of us who form the bridge between the before EMR and after EMR, it is significant.

    SETMA's "target" for 2009 is EXCELLENCE. The problem with this goal is that it requires persistency which will look like relentlessness. It will require, in Churchill's words, that we, "never ever surrender." We will be tempted to "surrender" to fatigue, or to convenience, or to expediency, but when surrender is rejected, excellence can be the result.  And, why would we choose excellence? We choose it because anything less is compromise and is unworthy of the "calling" which we all have as participants in the delivery of healthcare to our friends, families and patients. Lest the choosing of the goal of excellence be considered arrogant, after all, how can you judge excellence, in the words of Dr. Mark Wilson it must be stated, "Excellence is not a stop sign which you pull up to having - arrived.' Excellence is a direction in which you are going." Essentially, excellence is the determination to be better than you were before, with the constant goal of continuing to improve. Excellence does not happen by accident. It is intentional and its achievement requires the establishment of goals, objects, measures, reviews and critiques.

    However, excellence will never be achieved by design or by resolution; it will only be achieved by character. It is only as excellence is compelled from our heart and soul that we will have the resolve and the strength to daily and hourly pursue excellence. The drive to excellence which comes from within us has many faces. Some of those are found in a competitive spirit, but the good news about excellence is that I is not a zero-sum game, i.e., if you are excellent, it does not prevent others from being excellent as well.  Excellence is objective but it is not comparative. It is not like an examination in school where a bell-shaped curve determined who could receive an "A" for "excellence" and who would receive a "C" for "mediocrity." In fact, in life and particularly in the delivery of healthcare, in the short run those who are excellence may not have the best results because they accept the challenge of meeting the health care needs of the neediest.

    Today, I invite you to join the journey which will not end at a destination, but a journey which is defined by our commitment to a standard which is excellence. Only you can sustain that standard. Only you can relentlessly pursue that goal every day, every way, every time. No amount of scrutiny or auditing can achieve excellence which is not driven by your heart and soul.  Excellence as the standard for your 2009 story will be the inevitable result of caring for every person you see, every day this year. Caring is first the result of you seeing everyone as someone of import. For Christmas, I gave my wife a porcelain box which has the following hand-painted message on its top: "To the world you are one person, but to one person you are the world." So it is with each person we see each day, they must for the moment we "see" them become, "our world," receiving from us our full attention and caring.

    But excellence will also be seen as we apply the highest standards to that caring; standards which are defined by "best practices" and "national standards." Whether it is the care of a patient with diabetes, hypertension, heart disease, depression, anxiety, uncontrolled pain, etc., excellence requires the application of the best knowledge in existence and our best effort - every time.  This may be the greatest promise of electronic patient records (EMR). Designed and executed best, the EMR is a tool for excellence. The EMR provides a benchmark of excellence against which you can measure your performance every day with every patient. The EMR provides an objective standard for determining that you have applied "best practices" and "national standards" to every patient. And, when coupled with genuine caring for others; when coupled with that person being the world to you receiving your full attention as if they are the most important person to you, the EMR will fulfill its greatest potential.

    The commitment to excellence is an individual passion but it becomes a collective, organizational passion as two, then three, then ALL embrace from their heart and soul the same standard. Sustaining excellence is much easier when it is the product of a group's effort. Like the "three-fold cord which is not soon broken," the group sustains the one's commitment to excellence at times of fatigue and discouragement. The physics of the three-fold cord is that at the point of one cord's weakness another is strong and the reciprocal is also true. A cord which can only support 200 pounds, when intertwined with two equally strong cords, the three can sustain 2,000 pounds. So it is with our effort and commitment of excellence. What we cannot do alone, we can do together.

    August, 2012 -- SETMA has used the following phrase for years: “If you are going to make a change, it had better make a difference.”  The only way people are going to follow a leader is if that leader helps them define and fulfill their own vision.  I have always associated this phrase with an article which I read in a Continental flight magazine.  It turns out, my wife read it.  The article was about “change agents” and IBM’s transforming itself in the early 1990s.  I looked and looked for the reference to the quote and could not find it.  I even asked IBM executives about the article.  On August 8, 2011, I found it!  Early in SETMA, I wrote the SETMA Sentinel which was an in-office publication.  It was a way of communicating with all of the practice and of getting everyone to know each other.  It was our first step in team building. I would write it early in the morning and walk around and put a copy on everyone’s desk before they got to work.  Fourteen years and four months ago, the March 30, 1998 Volume IV Number III, the following Sentinel appeared.  SETMA Sentinel (An In-house Publication Designed for Team Building) Volume IV Number III March 30, 1998 Responses to SETMA.

    (Editor's Note: On February 5, 2003, Dr. Holly addressed the Massachusetts Medical Society's Medical Informatics meeting in Boston Massachusetts. Today's article and the next two weeks installments of Your Life Your Health are excerpts from his address which was entitled: "Beyond Electronic Medical Records: The Hope and Promise of Electronic Patient Management." Several years ago, I was browsing in a book store, and saw a book with a black fly leaf. I picked it up and it fell open to page thirteen. An interlinear jumped out at me, which stated: "Metanoia: -- A Shift of Mind." The paragraph went on to say, "(Metanoia is) the most accurate word in Western Culture to describe what happens in a learning organization&"

    I knew the word metanoia and I knew that it had nothing to do with business. As a Christian and a Bible teacher, I have studied, written and taught that word for years. It is the Greek word for "repentance," and means to "have a change of mind or to change one's direction." I was absolutely confident that it had nothing to do with American business. In order to "debunk" what the author said, I read Peter Senge's The Fifth Discipline. Needless to say, "I had a change of mind."  I found in Dr. Senge's book a structural and philosophical foundation for what we were already doing at Southeast Texas Medical Associates in Beaumont, Texas. I also found another illustration of a principle a friend had taught me years before: the person who helps you the most is not one who teaches you something new, it is the person who teaches you how to say that which you already know or suspect.

    April, 2013 -- 100 years ago today, the Titanic sank. Since that time, almost a dozen movies have been made about that tragedy and over 100 books have been written, the most recent in the past few months.  As we mark the centennial of this disaster, it is possible that more and more attention will be given to the Titanic.  The story illustrates at least two lessons.  One was not known in 1912, but should have been learned by the loss of the Titanic, and one is not known in 2012, but should be learned by our reflecting upon the fate of the Titanic.

    Trust in Technology - Misplaced

    The first lesson is that trust in technology is misplaced.  For centuries, the seas have been the highways of the world, but were fraught with danger.  Probably no greater fear faced sailors as they left their homeports than that of their ship sinking at sea.  The thought of one’s ship sinking below the cold, dark waters of the North Atlantic and the image of those same deep waters leaching the warmth of life out of one’s body in only a few minutes was enough to send dread into the heart of the bravest of men.

    But, in 1912, technology had overcome man’s fears:  the Titanic could not sink!  But, it did.  The unsinkable was sunk; the impossible happened.  And, now, 100 years later, evidence is mounting that the Titanic’s sinking may have not been from an “act of God” - a killer iceberg loose upon the sea - but defective rivets put in place by men.  How ironic it will be if the temerity of the men in charge of the Titanic - their “foolhardy contempt of danger” -- demonstrated by their rushing headlong into the dark night, encouraged by man’s “faith” in technology, resulted in the old seafarers’ worst fears being lived out again, because men used defective rivets in constructing the Titanic.

    Contained within Abraham Lincoln's famous "House Divided Speech," delivered to the Republican Convention on April, 16, 1856, is the imperative for data analytics and performance auditing by healthcare providers today.  Lincoln said, “If we could first know where we are, and whither we are tending, we could better judge what to do, and how to do it,”.  (Quoted by David Eisenhower in the Foreword to Churchill: The Prophetic Statesman, by James C. Humes, Regnery, New York, 2012) In any human enterprise, if the participants are unwilling to objectively and honestly face where they are, it is improbable that they will ever get to where they want to be, let alone to where they should be.