In 1997 through 1999, SETMA was learning “why” as opposed to “how” to use an EMR.  SETMA’s use of the EMR was not optimized by computer lessons; it was optimized by learning why we were using the EMR and then redesigning the display and deployment consistent with that rationale.

Four Seminal Events

In October, 1997, SETMA attended the Medical Group Management Association meeting to preview electronic-health-record (EHR) solutions.  In March, 1998, SETMA signed a contract with an EHR vendor.  We deployed the enterprise practice management (EMP) side of the system in August, 1998 and the EHR on January 26, 1999.  By Friday, January 29th, we documented every patient encounter in the EHR.  In May, 1999, four seminal events transformed SETMA’s healthcare vision and delivery. 

First, we concluded that EHR was too hard and too expensive if all we gained was the ability to document an encounter electronically.  EHR was only “worth it,” if we leveraged electronics to improve care for each patient; to eliminate errors which were dangerous to the health of our patients; and, if we could develop electronic functionalities for improving the health and the care of our patients.  We also recognized that healthcare costs were out of control and that EHR could help decrease that cost while improving care.  Therefore, we began designing disease-management and population-health tools, which included “follow-up documents,” allowing SETMA providers to summarize patients’ healthcare goals with personalized steps of action through which to meet those goals.  We transformed our vision from how many x-rays and lab tests were done and how many patients were seen, to measurable standards of excellence of care and to actions for the reducing of the cost of care.  We learned that excellence and expensive are not synonyms. 

Second, from Peter Senge’s The Fifth Discipline, we defined the principles which guided our development of an EHR and the steps of our practice transformation from an EMR to electronic patient management; they were to:

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

In 2009, we would discover that these principles are essentially the principles of patient-centered medical home and that the past ten years had prepared SETMA to formally become a patient-centered Medical home.  Between 2009 and 2014, SETMA would become accredited as a medical home by NCQA, AAAHC, URAC and The Joint Commission.

The third seminal event was the preparation of a philosophical base for our future;  developed in May, 1999, this blueprint was published in October, 1999.  It was entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine With Electronic Health Records which Evolves into Electronic Patient Management”.   The first eight pages of this current paper were developed from an update of this paper. 

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

1. Care where the same data base is being used at ALL points of care.
2. A robust EHR to accomplish the above.
3. A robust business-intelligence analytics system, which allows for real-time data analysis at the point of care.
4. A laser printer in every examination room so that personalized evaluational, educational and engagement materials can be provided to every patient at every encounter, with the patient’s personal health data displayed and analyzed for individual goal setting and decision making.
5. Quality metric tracking, auditing and statistical analysis.
6. Public Reporting of quality metric performance by provider name.
7. Quality Improvement initiatives based on tracking, auditing and analysis of metrics.
8. Shared vision among all providers, support staff and administrators - a personal passion for excellence -- which creates its own internalized, sustainable energy for the work of healthcare transformation.
9. Celebratory culture which does not compete with others but continually improves the organization’s own performance, using others as motivation but not as a standard.
10. Monthly peer-review sessions with all providers, to review provider performance and to provide education in the use of electronic tools.
11. Adequate financial support for the infrastructure of transformation.
12. Respect of the personal value of others and the caring for people as individuals.
13. An active Department of Care Coordination and a hospital-care support team which is in the hospital twenty-four hours a day, seven days a week.
14. Aggressive end-of-life counseling with all patients over fifty, and active employment of hospice in the care of patients when appropriate.

Fourth, we determined to adopt a celebratory attitude toward our progress in EMR.  In May, 1999, my cofounding partner was lamenting that we were not crawling yet with our use of the EMR.  I agreed and asked him, “When your son first turned over in bed, did you lament that he could not walk, or did you celebrate this first milestone of muscular coordination of turning over in bed?”  He smiled and I said, “We may not be crawling yet, but we have started.  If in a year, we are doing only what we are currently doing, I will join your lamentation, but today I am celebrating that we have begun.”  These four seminal events have defined SETMA’s EMR pilgrimage and are the foundation of our success. 

Updated on March 29, 2012, “Fourteen Years ago Tomorrow”

Fourteen years ago, tomorrow, on March 30, 1998, the partners of SETMA signed a $675,000 contract to purchase an EMR system which would revolutionize our delivery of healthcare.  There were only three of us and our accountant said, “You guys are surely now joined at the hip until death do you part.”  He laughed at our foolishness.  Colleagues in the community said, “What a waste; all that money, and no benefit to the patient!” 

Now, fourteen years later, SETMA is a national leader in the use of EMR to improve the quality of patient care and in the advancement of healthcare with electronics.  SETMA’s integration of EMR, laboratory data, hospital records, nursing home records and the new field of telemetrics, are all evidences that we made the right decision in 1997, which is when we decided to buy an EMR.  No one is laughing any more and many lament the fact that they did not join us in this pilgrimage soon to be fifteen years ago. 

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.