Dr. Anderson’s search for answers, which became the foundation of his book, came from stress, fatigue and frustration.  It led him to good answers but SETMA’s search for answers had a different stimulus.  Dr. Anderson said, “(In 2003) the electronic medical record (EMR) he incorporate into the practice in 1998 seems to be costing more time than its saving...Dr. Anderson is stressed and demoralized, feelings he shares with colleagues in 2003, as well as with many primary care practitioners now (2011).”   That has not been SETMA’s experience. 

We did find that adopting an EMR was difficult.  We began using the EMR January 26, 1999, ten months after we purchased it.  It took that long to build functions into the EMR.  In May, 1999, three months after we began using the EMR, we realized how hard this was.  A note contemporaneous with the events stated:

“(In May, 1999) two events defined our success with the EMR. They occurred simultaneously. The first was our realization that this task was too hard and too expensive if all we were to get out of it was the ability to document a patient encounter electronically....It was this realization which pushed us past electronic patient records to electronic patient management. We realized that we had to develop the functionality for the EMR to enhance the quality of patient care, to increase the satisfaction of patients themselves and to expand the knowledge and skills of health care providers, if it was to be ‘worth it.’

“SETMA's developed disease management tools, based on Peter Senge's concepts of ‘dynamic complexity’ and ‘circular causality’ (see The Fifth Discipline), therefore, we made this transition to electronic patient management and the investment of time and money suddenly was ‘worth it.’

“The second event set the tone for the next six years of EMR implementation. In a moment of frustration at the new system, which at this point of development was cumbersome to use and yielded little more than an acceptable record of a patient encounter, one partner said, ‘We haven't even begun to crawl yet,’ speaking of our use of the EMR. SETMA's CEO said, ‘You're right, but let me ask you a question. When your oldest son first turned over in bed, did you lament to your wife, “this retarded, spastic child can't even walk, all he can do is turn over in bed,” or did you excitedly announce to your wife, “he turned over in bed”'?’  He smiled and the CEO added, ‘If in one year, all we're doing is what we are presently doing, then I'll join your lamentation. For now, I am going to celebrate the fact that we have started and that we are doing more than before.’”"

“That celebratory attitude has given SETMA the energy and resolve to face hard times and the vision of electronic patient management has given us direction and substance to our goal. Today, we are not what we were, and we are not yet what we shall be, but we are on a pilgrimage to excellence which will never end. We started eight years ago at MGMA; where is the end? There isn't one and that is what helps us get up day after day, excited about the prospect of the future.”

SETMA’s progress was driven by a passion and by a vision, both of which gave us joy in the midst of hard work.  While pursuing electronically and technologically-driven excellence, on May 11, 2000, SETMA renewed our commitment to personal care and personal caring for people as unique and important individuals.  We stated:

“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.”

SETMA’s migration to team-based care, to electronic patient management and to patient-centered medical home was a positive move; it was not motivated out of frustration, fatigue or fear of the future.  The EMR was initially hard but it very quickly became a tool for excellence and a tool for success, making it easier to “do it right” than not to do it at all.  Our deployment of the EMR made complex tasks easy and enabled SETMA to advance rapidly with quality improvement, public reporting of quality metrics and transforming our delivery of healthcare.

In chapter one of his book Dr. Anderson said, “...if we as a nation are hoping to provide  medical coverage for as many people as possible, we have to make sure that a sufficient number of doctors €“ as part of a larger, integrated system -- are available to care for those people.”  In this chapter, Dr. Anderson speaks of his nurses coming to the point that they were enjoying the team approach to healthcare so much that they wanted to “burn their boats” so as never to go back to the old ways. 

I smiled as I read this because SETMA had a “Cortez Plan” as well.  This relates to the great explorer whose soldiers wanted to return to Spain.  He made it impossible. Commonly, it is thought that he burned his ships but in fact he did not.  He scuttled them.  He knocked holes in them and let them sink.  SETMA did the same thing.  We did so by talking about what we planned, rather than boasting, we declared our goals. That way we could not “go back” without looking foolish and without having to admit failure.  We also had a “Fahrenheit 451 Project,” where we determined to “get rid of paper.”  Anyone who wishes to change must come to that point of “no return,” and as was the title of a movie, “Damn the Torpedoes; Full Speed Ahead.”

Dr. Anderson names his change Family Team Care Model and the experience of many innovators and transformers of care mirror those of Dr. Anderson.  The greatest strength of Dr. Anderson’s book which I think is more for those who have made part or most of the journey from frustration to patient-centered medical home.  At SETMA.com under Your Life Your Health, there are over 100 articles which SETMA has published on patient-centered medical home since February 16, 2009, so we will not review all of the content of this part of this book.  Dr. Anderson’s history of this movement is extremely valuable and well done.

The weight of Dr. Anderson’s book is in giving an excellent summary of the history of PC-MH, of IBM’s contribution to this process and particularly of Dr. Paul Grundy’s contribution, of the Patient Centered Primary Care Collaborative and of the leaders of each of these movements. This book will be a reference book for years to come.  As he moves from frustration to Team Based Care to Patient-Centered Medical Home, Dr Anderson shows us the roadmap of healthcare transformation over the past twenty-five years.

 SETMA wrote its history of change in The Future of Healthcare Innovation and Change -- SETMA’s Model of Care Patient-Centered Medical Home (http://jameslhollymd.com/the-setma-way/setma-model-of-care-pc-mh-healthcare-innovation-the-future-of-healthcare), which began and ended with the statement:  “Efforts to reform healthcare may fail unless they employ four elements upon which SETMA depends in its transformative efforts:

1. “The methodology of healthcare must be electronic patient management.
2. “The content and standards of healthcare delivery must be evidenced-based medicine.
3. “The structure and organization of healthcare delivery must be patient-centered medical home.
4. “The payment methodology of healthcare delivery must be that of capitation with additional reimbursement for proved quality performance and cost savings.”

All of these concepts are consistent with The Familiar Physician.  I recommend this book to all who are making the medical home journey, who have made it or who are thinking about making it.