Eighteen years ago, SETMA realized that electronic patient records (EMR) in and of themselves would not provide the transformative power required to radically change health care delivery, but that the analytical power of electronic data analysis could. Therefore, in May, 1999, SETMA determined to change from pursuing EMR to pursuing electronic patient management (EPM).  In that month, SETMA began designing clinical decision support (CDS) tools and disease management tools (DMT) which would facilitate individual patient care and also would allow the improving of care for populations and panels of patients.  (see SETMA: May, 1999 - Four Seminal Events)

One of the measures of the value of innovation is “how long does it last,” and “how long is it effective in promoting and measuring quality of care?”  January 2017, SETMA enters our 23rd year of existence – personally, I enter my 44th year of medicine – as SETMA looks back on those early days, and as we see what has lasted, we are encouraged that the vision and aspirations we had in the beginning are still with us today. 

As we developed CDS and DMT in 1999, we realized that some things were common to all of these tools.  Among those commonalities was the desire to address three things with EVERY patient we see, i.e. weight management, exercise and smoking cessation.  From this came the LESS Initiative.

What is the LESS Initiative?

LESS stands for:

L -- Lose weight
E -- Exercise
S -- Stop
S -- Smoking

No one would argue that each of these is not valuable in anyone's life or health.  But the complexity is to confront an entire patient group with all three elements consistently, every time they seek healthcare.  To address these in a single patient is simple, but how do you consistently address these issues in over 500-1,000 patient visits a day and in over thirty different clinical settings?

Here's how the Initiative works. Every time a patient is seen in the clinic, no matter what the occasion for the visit is, they will be alerted to the health risk of:

• Their current weight, as measured by their body mass index (BMI) and their body fat content as measured by electrical impedance.  Each patient will be given a Weight Management Assessment document which tells them their disease risk associated with their current BMI and their waist measurement. They are given their percent body fat and an explanation as to how a 5% to 10% change in their weight will impact their health and future.  Their basal metabolic rate (BMR) is also calculated and the number of calories required to maintain their current weight is given to the patient.
• Their current level of activity.  Each patient is given information concerning the benefit which the heart, lungs and health receive from participation in exercise as indicated by "aerobic points." The patient is given the level of aerobic fitness which that exercise achieves for them, i.e., fair, good, excellent, etc., and the patient is given a recommend minimum exercise level which they need in order to achieve a "good" aerobic status for their age and sex. This exercise prescription will include information on how to increase the number of steps they take each day in order to have an "active" lifestyle which is defined by taking 10,000 or more steps a day. 
• The imperative for stopping smoking. Even the tobacco companies' websites now state, "The only way to avoid the health hazards of tobacco smoke is to stop smoking completely." This is clever because with this warning, the tobacco companies, while continuing to encourage tobacco smoking, have immunized themselves from future litigation because they now warn you that their product is harmful. Now, legally, the only one to blame for the harmful effects of smoking is the smoker, even though nicotine is addictive. Also, the initiative includes the questioning of patients about exposure to "environmental tobacco smoke" or "second hand smoke," either at home or at work and now “tertiary smoke” risk which is experienced by being around people who smell of tobacco smoke.

The following documents are given to each patient, each time they come to the clinic:

• Weight Management Assessment - one page
• Exercise Prescription - 7 pages
• Smoking Cessation - 7 pages -- Smokers will be given the full smoking cessation document.  Non-smokers who are at work or at home with a smoker will be given a document on the hazards of what has been variously called "environmental", "second-hand" or "passive" tobacco smoke and now “tertiary smoking.”

While this initiative may seem to be simple, it is a complex undertaking. To do this occasionally is simple, but to consistently do it every time a patient is seen is not. At the end of each day, a report will be run which will determine if the above three documents were generated in the electronic medical record and if they were actually printed. A random sampling of patients leaving the clinic during the day will be used to develop confidence that the documents have actually been given to patients.

The value of the elements of the LESS Initiative is obvious, but now, sixteen years later, value is not only seen by the fact that we continue to do it, but also by the public health initiatives which now require elements of the LESS Initiative to be performed by all healthcare providers.  In 2006, as previously reviewed here (SETMA’s Innovations Over the Past Twenty Years Have Prepared Us for MACRA & MIPS), the Physician Quality Reporting Initiative (PQRI) was started as a voluntary program which rewarded practices which measured and reported quality metrics.  In 2011, that program was changed to the Physician Quality Reporting System (PQRS) which was no longer voluntary and for which a bonus was not paid but a penalty would be assessed if practices did not report quality metrics.  One of the changes in PQRS was that the body mass index (BMI) had to be reported. 

When the Meaningful Use Program was established by the Health and Human Services (HHS), calculating the BMI was no longer enough.  Each healthcare provider had to explain the BMI to the patient and had to explain the health implications of an excessive BMI.  Meeting Meaningful Use standards also required providers to address whether or not the patient smoked and also required that smoking cessation strategies be discussed with the patient.  SETMA’s LESS Initiative, active since 2000, more than fulfilled all of these PQRS and Meaningful Use Standards.

In 2004, The Agency for Healthcare Research and Quality (AHRQ) created the AHRQ Health Care Innovations Exchange.  This is the link to the exchange:  http://www.innovations.ahrq.gov/. AHRQ explains the goal of the exchange: The Innovations Exchange helps you solve problems, improve health care quality, and reduce disparities.

• Find evidence-based innovations and Quality Tools.
• View new innovations and tools published biweekly.
• Learn from experts through events and articles.

There are presently over 500 innovations and quality tools published by AHRQ.  There is a rigorous application process to have an innovation accepted and then professional writers prepare the description of the innovation for publication on the Exchange.

In May, 2011, AHRQ accepted SETMA's LESS Initiative for publication on their Innovation Exchange.  The affirmation of SETMA’s initiative by PQRS, Meaningful Use and AHRQ encourages SETMA to continue our innovation as we did by publishing on December 5, 2016 another tool which encourages SETMA providers to practice excellence medicine and which makes that practice easier and measurable.

Shared Responsibilities

Consistent with the “team approach” to health care delivery, the LESS Initiative is dependent upon the sharing of responsibility by the various members of SETMA's healthcare team:

• The IT team (Information technology) has to make it possible to easily and conveniently produce the documents and to audit the performance.
• The Nursing and support staff have to collect the data - weight, height, waist size, abdominal girth, hip measurements, neck size, chest size, body fat, etc. - which allows the computation of the information used in determining the patient's health risk.
• The Nursing Staff have to create, print and distribute the documents, as well as initiate the discussion with the patient of the information in each.
• The Healthcare Providers - physicians and nurse practitioners - have to interact with the patient about the imperatives for change which are indicated by the information in the document, discussing with the health risks of doing nothing and the health benefits of changing the lifestyles...
• The Nurse Management Staff must audit the charts at the end of the day to make certain that this has been done. It has been established that 95% effectiveness is the standard for determining success.

Since the development of this tool, SETMA has deployed dozens of other tools which have facilitated the consistent performing of important tasks and functions.  All of these have contributed to the building of SETMA's PC-MH.