In December, 2016, we began this series. The first two installments were on the LESS Initiative (December 8th) and Patient-Centered Medical Home (December 15th).  Our goal is to review the core values and functions which have enabled SETMA to connect the past with the present and to prepare for the future (Continuity); to illustrate the ingenuity and healthcare transformation which have been central to SETMA’s progress (Creativity), and to allow SETMA to sustain the progress of the past, tying it to the needs of the future, enabling SETMA to relentless pursue excellence in patient care quality and safety (Consistency). 

When SETMA was formed between May and August, 1995, I had been in solo practice for twenty years.  While I had used dictation and transcription for medical record keeping, which was a step above hand-written notes, the records still did not allow for measuring performance.  In August and September, 1995, it became apparent that to succeed in a multi-provider setting, we would have to measure performance and compare performance among providers. 

Early on, this measurement focused on productivity rather than quality and safety.  As we realized that it was almost impossible to measure quality with paper records, we began to talk about a relative new idea:  electronic records.   In 1997, the complexities of medical record keeping in a growing multi-specialty practice pressed SETMA toward a different medical-record keeping methodology, i.e., electronic medical records (EMR).  In March, 1998, SETMA purchased an EMR and began the transition from Dictaphones and transcription to computers. 

Even though the system we purchased was among the best and has remained so over the past twenty years, it did not provide the ability to create a record but only the ability to create the capability of electronically creating a medical record.  It took us from March, 1998 to January 26, 1999, to create the capability to use the computer to create a record of a patient encounter at the point of care. 

By May, 1999, it became apparent to SETMA that this tool was very hard and very expensive and if all it provided was the ability to create a record of a patient encounter electronically, it was not worth the effort.  In that month, we changed our goal from electronic medical records to electronic patient management.  In that month, we determined that our goal was to use electronics to improve the quality and safety of the care we provide to patients and not just to document patient encounters.  This meant that our focus had to change from productivity to quality and safety.  It meant a radical change to focusing on improving the care our patients received and to focusing on the ability to measure quality and to prove that the quality of care for individuals and for groups of patients was actually improving through auditing our performance.

In May, 1999, we defined ten principles of how to develop an EMR and a transformative medical practice.  The principles were:

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

Also in May, 1999, we published a booklet entitled:  More Than a Transcription Service: Revolutionizing the Practice of Medicine: And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management (see at:  More Than a Transcription Service: Revolutionizing the Practice of Medicine And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management

The tools needed for that purpose did not exist, so we began developing disease management tools and clinical decision support tools.  We began to measure preventive and screening care and we began to employ “quality metric sets” developed by groups like the Physician Consortium for Performance Improvement (PCPI).  In 1999 and 2000, we realized that the future of healthcare was going to require us to know whether all of our patients were receiving excellent care individually but also whether or not certain groups were also receiving equal care. 

In 2000, we began using statistical analysis to see if our care was improving over time and whether subgroups were receiving comparable care.  This meant that we wanted to know if African Americans were receiving the same caliber and standard of care that Caucasians were receiving. To do that we began measuring the care of both groups and of others groups. 

By 2008, SETMA’s auditing functions had grown and were requiring more and more time and energy to produce the reports which allowed us to measure and to improve our performance.  At that time, EMRs did not provide the significant auditing tools which they do now so SETMA adapt a “business intelligence” software package to medicine.  Once developed, it allowed us to complete audits in less than 60 seconds and eventually in less than 30 seconds which had previously taken hours and days to complete.

In 2009, we deployed this new auditing capability and in July, 2009, announced to ourselves that we were going to begin the “pubic reporting by provider name” on multiple quality metric sets.  This had never been done before and it was a little daunting.  Today, January 3, 2017, we begin our 9th year of public reporting of provider performance at www.jameslhollymd.com on over 200 quality metrics.  (see:  Public Reporting - Reporting by Type). 

In 2013, while reading a new book about Winston Churchill, I read the following from the foreword:  “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.  This concept is discussed in more detail at; 
Abraham Lincoln and Modern Healthcare,