March 7-10, 2011, six of SETMA's colleagues attended a workshop in Warren, Massachusetts entitled, "Leading for Health: Realizing Better Health, Better Care and Lower Cost Through Systems Leadership." The workshop was sponsored by the Society for Organizational Learning and the Fannie E. Rippel foundation (www.rippelfoundation.org). The principle facilitators of this workshop were:

• Peter M. Senge, a senior lecturer at the MIT Sloan School of Management, and the founding chair of SoL, the Society for Organizational Learning, a global network of learning communities addressing profound institutional change. A renowned pioneer in and writer about management innovation, Peter is the author of the widely acclaimed The Fifth Discipline: The Art and Practice of the Learning Organization, and most recently The Necessary Revolution: How Individuals & Organizations are Working Together to Create a Sustainable World.
• Claire Sherry Immediato is the founder and president of Heaven & Earth Incorporated and served as SoL's president and managing director from 2001-2010. Sherry represents SoL in the ReThink Health initiative and leads SoL's work on increasing health and well-being in communities. She is the co-author of Creating Integrated Care and Healthier Communities. She was the lead faculty member of the national Public Health Education Leadership Institute for its duration from 1998-2006, and currently serves on the faculty of the CDC-sponsored national Environmental Public Health Leadership Institute as well as a number of regional public health leadership institutes.

The pamphlet introducing the workshop stated:

"What would it mean to create health and well-being in our families, organizations and communities? When most of us talk about health, we are really referring to a reduction in illness. That's partly because we spend one-sixth of the US economy on health care, which is largely illness care. Reducing the cost of care is a critical part of creating a sustainable system. We also need to consider that 80-90% of factors that are determinants of our health are NOT directly connected to health care delivery."

Some of the provocative questions which the workshop was designed to address were:

• "What are our visions of health and well-being individually and collectively? How do we identify and bring together the key stakeholders to develop a shared vision for health in our communities?
• "What specifically are our hypotheses about leverage points for improvement and how they can be activated? How can we respect our different agendas and still take aligned action?
• "How can we effectively partner across systems to achieve better health, lower health care costs and better quality and access to care and other resources?
• "How do we create health and well-being from the inside out?"

At this point, this reflection on the workshop becomes personal which simply means that there is neither intention to nor claim of reporting the meeting in an objective manner. From here forward this review is this author's personal recollections. It may or may not reflect how others viewed the meeting and while none of the ideas contained herein or claimed by me to be original, neither is it claimed that they can be blamed on anyone else.

Foundation of SETMA

Soon after the founding of SETMA in 1995, we became aware of Peter Senge's The Fifth Disciple. A detailed of SETMA utilization of that work can be found at these links or below:

• Peter Senge, The Fifth Discipline and Electronic Patient Records
• Beyond Electronic Medical Records: The Hope and Promise of Electronic Patient Management
• Designing an EMR Guided by The Fifth Discipline by Peter Senge, PhD
• Healthcare: Metanoia -- A Shift of Mind

The systems thinking detailed in The Fifth Discipline has been an active guide for the development and growth of SETMA. Naturally, when we discovered that a conference on the transformation of healthcare was being planned by Senge and his associates, we wanted to attend. We invited and encouraged others to attend as well including several colleagues from Diabetes Center of Excellence, Texas A&M School of Rural Public Health and NextGen, the EMR vendor on whose platform SETMA has built our electronic patient management tools.

"Health," "In Need of care," "In Care"

During the workshop the fundamental schematic for understanding healthcare transformation was the following structure which was depicted by three boxes, each a progress from one to another:

• Health
• In Need of Care
• In Care

Except for those who are born with congenital or genetic abnormalities everyone starts life essential in a state of health. Most people, during their life, progress from that state to a state of needing care because of the loss of their health and final into a state of receiving care. The phrase "healthcare" has been intentionally avoided here as the care we are receiving is more aptly defined as "illness care" or "disease" care Ideally, those who are "in care" would be moved back to a state of "health," but most often are simply returned to a state of being "in need of care."

Considerable attention to a definition of "health" was given. It was generally accepted that most often when we talk about "health," it is defined in terms of the absence of illness or disease. That description was rejected, and, it was determined that "health" referred to a "state of well being which involved physical, emotional, mental, and spiritual balance in life". The "disease" model of a description or definition of "health" was rejected because we could all name prominent and non-prominent people who while they had serious illnesses or disabilities would nevertheless be described as healthy.

Determinants of Health

In this context, we affirmed the statement above that, "80-90% of factors that are determinants of our health are NOT directly connected to health care delivery." If that is the case, what are the determinants? Without doubt, education is at the root of "health." This is not because of the cognitive function of education, i.e., that people with the most education or intellectual capacity are the healthiest. Being informed allows choices to be made which sustain or support heath. Unfortunately, many people get their "information" from advertisements which are entrepreneurial without regard to the health of those who are being affected by the content of ads.

How you judge the place of personal freedom and public responsibility will be affected more by your political philosophy than by science but virtually everyone agrees there is a place in public policy for the protection of those who are not yet mature enough to make rational health choices. Public policy has dictated the limitation of cigarette and alcohol advertisements from media principally directed at children. The future of health education will involve more discussions about sugar, salt, transfats, processed foods, preservatives and other "food products" which are contributing to the loss of health. Where the balance is between personal freedom and public health policy will continue to be debated but there is little debate over the fact that currently the reality is "out of balance."

For years, SETMA has argued that diet and activity are the foundations of maintaining your health but physically and mentally. Both knowledge gained by children in a "healthy" educational setting and the efforts of informed Public Health agencies contribute to maintaining one's position in the "health" position rather than being "in need of care" or being "in care." Health promotion through healthy, personal choices needs to be a part of the curriculum of schools starting with the education provided by what is served and made available to children in the education setting.

Public Health - a Rich History of Heath Promotion

Sometimes we forget that the greatest advances in personal and community health have come through public health initiatives. Some of these have been:

1. Sanitation
2. Clean water
3. Immunizations
4. Control of disease-spreading vectors such as mosquitoes, rats, fleas, etc.
5. Nutrition in the treatment of scurvy, rickets and other illnesses which result from specific nutrient deficiencies.
6. The removal of lead from paint, particularly in toys which children put into their mouths.
7. And, many, many more

Changes in the "Health Care System"

During the first day of the workshop, the participants were asked to write down "What Do I stand for in healthcare?" I wrote:

• Access to and affordability of healthcare for all
• Accountability for excellence for outcomes for all health care providers and organizations.
• Transformation - not reformation - of health care because transformation is the results of internalized passion which is generative (creative), sustainable and self-motivated.
• Transformation trough four domains.

Those four domains are:

• The Substance of Healthcare Transformation -- evidenced-based medicine and comprehensive health promotion
• The Method of Healthcare Transformation -- electronic patient management (as opposed to electronic health records)
• The Organization of Healthcare Transformation -- patient-centered medical home
• The Funding of Healthcare Transformation -- a system like Medicare Advantage (capitation with payment for quality outcomes)

We believe that the SETMA Model of Care supports each of these domains. Briefly that model includes these five steps:

• Tracking of over 200 quality metrics including the concepts of clusters and galaxies of metrics at the point of care with each patient seen at SETMA.
• Auditing by patient panel or population of all patients seen at SETMA.
• Analyzing with statistical methodology the tracking and auditing data in order to find leverage points for patient-care improvement of all patients seen at SETMA.
• Public Reporting by provider name of the audited process and outcomes metrics of all patients seen at SETMA.
• Quality Improvement initiatives based on the data derived from the first four steps, including active and intentional promotion of health.

Comprehensive Wellness

Recently, in a discussion of the elements of patient-centered medical home, Dr. Sam Romeo, whose practice was one of the first medical homes in the nation and who is a surveyor for the Accreditation Association for Ambulatory Health Care (AAACH), stated that medical home involved:

"Comprehensive -- wellness, healthy life style, health risk appraisal, prevention,
and end of life care are even more important to assess, document and foster. Coordination of disease care, while important and is a part of acute and chronic care,
is chasing the horse after he has left the barn."

In my judgment, his statement effectively summaries this part of the workshop's discussion. In "health," there is "care" which is needed. When this concept was addressed in the workshop, Dr. Senge responded, "That would be true €˜health' care!" He is right.

Promoting Patient Health

The care which is required in the presence of health is dictated by the fact that age, genetics, environment and choices all often have an adverse affect on our state of health continually moving us toward the position of being "in need of care" or "in care."

Prevention, Screening, Surveillance

• Preventive care involves immunizations and recommendations for health life styles principally involving nutrition and activity.
• Screening care involves detecting curable illnesses before they develop beyond the point of cure such as breast cancer, colon cancer, cervical cancer, and prostate cancer.
• Surveillance care involves mapping a patient's personal history and family history to potential diseases and/or recurrence of cured diseases in order to promote health.

At the root of each of these is a comprehensive patient history (family, social, habits) which is an integrated and interactive part of the patient's personal health record.

Risk Stratification

Health promotion involves identifying patients who are at increased risk of disease and accessing their current state of health, based on evidenced-based medicine, and providing them care which will preserve their health. Currently, SETMA employs the following risk assessments:

• Diabetes
• Hypertension
• Cardiovascular (Twelve Framingham Risk Scores with "What If" Scenarios for showing patients that "if they make a change, it will make a difference."
• Cardiometabolic Risk Syndrome
• Insulin Resistance which is also a part of Cardiometabolic Risk

This assessment will suggest where the most leverage is in supporting a patient's efforts to maintain their health.

Healthy Life Styles

Health promotion and care in the state of health relate to healthy life styles including nutrition, weight, exercises and the avoidance of tobacco smoke, excessive alcohol consumption, illicit drugs, emotional stress, socialization, proper rest and mental stimulation.

Ten years ago, SETMA designed the LESS Initiative under Your Life Your Health). "L" stands for "lose weight; "E" stands for "exercises," and "SS" stands for "stop smoking." A weight assessment, personalized exercise plan and primary, secondary or tertiary tobacco smoke exposure is completed at each visit. A fifteen-page document is given to the patient for study and action. It is reviewed at each visit.

As of mental and emotional health, an illustration makes the point. An elderly lady presented to clinic with deep depression and despondency. During counseling it was discovered that her only son had recently died tragically. After consoling the patient, it was recommended that she find a young boy, who did not have a mother or a grandmother. Mother him or give him the attention a grandmother gives to a child. The lady returned two months later and declared, "I found him." She was bright and smiling. Until her death, here life was fulfilled with the giving to and the loving of this "adopted' child.

Wellness and health involve more than the absence of illness.

End of Life Measures

In all of our discussions about health, we must accept that no matter how healthy we are, we will all die. It is possible to die "well" and that possibility is enhanced if we have thought about the care we desire when death approaches. Documenting in the patient's health record their instructions for end-of-life care helps them preserve one of the most important parts of health which is autonomy: the ability to make one's own health care decisions. In addition, it allows society to begin dealing with the public policy issue that often the majority of life-time healthcare costs are related to care at the end of life which care and cost does not result in health, quality of life or quantity of life.

In the coming weeks, we will review more of this workshop and its implications for SETMA and for our society.