In October, 1999, four years after the founding of SETMA; nineteen months after SETMA had purchased the EHR which we continue to use today; nine months after SETMA started using the EHR to see patients; and. soon to be twelve years ago, we published a pamphlet for our patients entitled, More Than A Transcription Service: Transforming Healthcare with Electronic Medical Records. (A short form of this paper can be found below)

We shared this booklet with our patients and colleagues as it described the future of healthcare, which SETMA wished to participate in bringing into existence. In the last paragraph of this paper (in the original the following was the last paragraph but in the edition of this paper which was presented in May, 2000, at TEPR, it appears on page 7), we said:

“Healthcare providers must never lose sight of the fact that they are providing care for people, who are unique individuals. These individuals deserve our respect and our best. Healthcare providers must also know that the model of healthcare delivery, where the provider was the constable attempting to impose health upon an unwilling subject, has changed. Healthcare providers progressively are becoming counselors to their patients, empowering the patient to achieve the health the patient has determined to have. This is the healthcare model for the 21st Century and the computerized patient record is the tool, which makes that model possible.” (Emphasis added) (October, 1999, More Than A Transcription Service, for the full article see below.

“Healthcare providers progressively are becoming counselors to their patients, empowering the patient to achieve the health the patient has determined to have:-- this is the core concept of medical home. It is an expression of the centrality of the patient to medical home and of the active involvement of the patient in their care. This differs from the traditional concept of the patient being a passive recipient of care directed solely by the healthcare provider. No longer a spectator to their own care, Medical Home patients participate in determining their goals, in designing processes for addressing those goals and in achieving those goals.

A second element of Medical Home illustrated by SETMA’s early experience is that while no provider can know everything about a patient - patients and providers do not share the same experiences and often don’t have the same “data dictionary” with which to understand those experience. The words patients and providers use and the values they place on symptoms may differ. Yet, the provider must know enough in order to consult effectively with the patient about their health. The same May, 1999, monograph referenced above, said:

“Recently, the mother of a prominent citizen in our community became our patient. After completing an extensive history and physical utilizing the computerized patient record, I asked this lady, ‘Do you think I now know you well enough to make appropriate decisions about your healthcare?’” She responded, ‘You know more about me than the doctor who has taken care of me for twenty years. He has never asked me all those questions.’ This testimonial can be repeated multiple times. EHR creates tremendous confidence in the patient that an accurate and complete database is available to the healthcare provider.

“As an extensive database is created on each patient, the patient’s confidence in the provider’s decision making increases. As the computerized patient record is ‘sold;’ to the patient, the patient becomes the provider’s greatest ally in producing an excellent record, which is complete and accurate. Also, when the encounter is completed and a copy of the record is given to the patient:

• “The patient is able to review the record, further gaining confidence that “if my doctor knows all of this about me, he/she must be making the right decision.”
• “If any data is inaccurate or has become invalid, the patient can correct the record, becoming a partner with the provider in the process of producing a complete, accurate, valid and current medical record.”

In a future article on medical home, we will discuss the place of the record in the continuum of care issues surrounding medical home, but this episode illustrates the power of a database which is available at every point of service. In addition, documenting every encounter in the same database whether inpatient, outpatient, emergency department, nurse home, hospice, home health, physical therapy, etc, allows the patients medical record to morph from at best a silhouette into a granular portrait of the patient’s health and condition.

The Baton

The following experience further illustrates SETMA’s early efforts at using a “healthcare baton.” I remember the morning. I arrived in the hospital at 5 AM to begin morning rounds. I always walked through the emergency department to see if any of our patients were there. This event transpired in November of 1999. The contemporaneous record of this event from More than a Transcription Service states:

“Recently, an elderly patient of mine came to the emergency room at 5:30 AM. I met her there as she walked in. When she sat down in the exam room, she pulled out of her purse a copy of her computerized patient record from her last visit to my office. It was complete and had all of her past history, allergies, medications, diagnoses and physical examination. I have known this patient for twenty-five years, but this record was more complete than my memory. I was able to quickly assess her condition and safely allow her to return home, without further testing. After dictating an emergency room encounter note (we were still six months away from having our EMR in the hospital), which would appear as if I had spent hours with the patient rather than a few minutes.”

This event accelerated the effort to deploy SETMA’s EMR into the hospital, the emergency department, indeed, into all points of service. It showed us how important it is to have the patient’s data available every where.

Another element of Medical Home involves the patient’s access to their health information. In a September 21, 2001, Your Life Your Health article, the following appeared:

“The Health Information Coalition (a local organization designed to integrate care in Southeast Texas) shares SETMA's philosophy about health information. In fact, ‘Your Life -- Your Health’ is derived from this philosophy. In the past, healthcare providers were viewed as and often functioned as ‘constables’ attempting to impose health and healthcare upon unwilling or partially willing subjects, who are called patients. In the 21st Century, much of the mystery of healthcare information is being removed by the easy access which so many have to so much information. Therefore, there has been a shift from healthcare providers being ‘constables’ to their being ‘counselors’ who empower patients to achieve the health which they have determined to have. Previously, patients were ‘told’ what to do and they either complied or didn't. Today, healthcare providers are inviting ‘people’ to take charge of their own health. Healthcare providers are encouraging patients to adopt healthy habits, avoid unhealthy activities and recognize the danger signs of approaching illnesses.

“Preventive health is really becoming ‘pro-active’ health where the patient and the provider collaborate to make good choices to retain or regain as good a state of health as is possible for every individual. SETMA and the Health Information Coalition is the vanguard of Pro-active Health. The Coalition will soon announce a new service to Southeast Texans called First Nurse. Watch for the announcement and learn how First Nurse will benefit your family.

“In order for this paradigm shift to succeed, patients must have more access to their healthcare provider and healthcare providers must have an expanded ability to communicate with the patients who entrust their health to them.”

This was written in 2001, eight years before anyone at SETMA had heard the term “Medical Home.” (see the full article at www.jameslhollymd.com Your Life Your Health, ‘So Much Information; so many experts; who to believe,” September 21, 2001) These key concepts about Medical Home are reflected in this 2001 article:

1. Health and wellness are critical to the functioning of a medical home
2. Preventive Health is imperative to the medical home
3. Patients taking charge of their own care are central to the medical home
4. Patients having access to their own healthcare information is part of medical home
5. Patients having increased access to their providers in the office, outside of the office, on the telephone, through a Health Information Exchange and through a secure web portal are all part of medical home.

These ideas, which have been a part of SETMA’s care for the past sixteen years and which became a part of our written philosophy twelve to fourteen years ago, are now symbolized by THE BATON. SETMA’s new posters, entitled “SETMA’s Healthcare Philosophy,” which are display in our offices, reflect:

• The patient is in charge of their own care 8,760 hours a year - full time.
• The “healthcare race” belongs to the patient, not to the provider - the patient is responsible for success in healthcare.
• The provider is a coach, a counselor, a consultant, a colleague to the patient; the provider is not the boss.
• The plan of care and the treatment plan, developed with the patient and agree to by all members of the medical home team, is the tool - the Baton - which enables the patient to lead his own healthcare team.

Increasingly, the Baton will be the symbol of the medical home’s transfer of care responsibility from the provider to the patient. (For more on The Baton see below). The Baton illustrates:

• That the healthcare-team relationship, which exists between the patient and the healthcare provider, is key to the success of the outcome of quality healthcare.
• That the plan of care and treatment plan, the “baton,” is the engine through which the knowledge and power of the healthcare team is transmitted and sustained.
• That the means of transfer of the “baton” which has been developed by the healthcare team is a coordinated effort between the provider and the patient.
• That typically the healthcare provider knows and understands the patient’s healthcare plan of care and the treatment plan, but that without its transfer to the patient, the provider’s knowledge is useless to the patient.
• That the imperative for the plan - the “baton” - is that it be transferred from the provider to the patient, if change in the life of the patient is going to make a difference in the patient’s health.
• That this transfer requires that the patient “grasps” the “baton,” i.e., that the patient accepts, receives, understands and comprehends the plan, and that the patient is equipped and empowered to carry out the plan successfully.
• That the patient knows that of the 8,760 hours in the year, he/she will be responsible for “carrying the baton,” longer and better than any other member of the healthcare team.

The genius and the promise of the Patient-Centered Medical Home are symbolized by the “baton.”  Its display continually reminds the provider and will inform the patient, that to be successful, the patient’s care must be coordinated, and must result in coordinated care.  As SETMA has expanded the scope of our Department of Care Coordination, we know that coordination begins at the points of “transitions of care,” and that the work of the healthcare team - patient and provider - is that together they evaluate, define and execute that plan.